Information Collection

Providers/Administrators

IC 190422 under ICR 201503-0930-003 · OMB 0930-0307.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Provider-Administr Providers/Administrators	Form and Instruction
Provider-Administr Provider-Administrator Provider-Administrator - Instruments.pdf	Form and Instruction
Provider-Administrator - Other.pdf Provider-Administrator	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	Provider-Administrator	Provider-Administrator	Provider-Administrator - Instruments.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 275

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	34,204	-100,248	134,452
Annual IC Time Burden (Hours)	1,333	-11,206	12,539
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Provider-Administrator	Provider-Administrator - Other.pdf	03/25/2015

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.