Information Collection

Provider Association Survey

IC 216130 under ICR 201504-0930-001 · OMB 0930-0351.

Documents and Forms

Document Name Document Type
Form Workforce Study Pr Provider Association Survey Form and Instruction
Workforce Study Pr Workforce Study Provider Assoc Dir Survey Attachment 1_ATTC Workforce Study Provider Assoc Dir Survey_12-4-14.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Provider Association Survey	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	Workforce Study Provider Assoc Dir Survey	Workforce Study Provider Assoc Dir Survey	Attachment 1_ATTC Workforce Study Provider Assoc Dir Survey_12-4-14.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 50	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	50	50
Annual IC Time Burden (Hours)	13	13
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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