Information Collection

Survey on Rural Community Wealth and Health Care Provision - Mail/web survey with health care providers_respondents

IC 202481 under ICR 201508-0536-002 · OMB 0536-0072.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Annex F_Health care provider questionnaire.docx	Other-Questionnaire
Rural Community Survey Pilot Study Report_Providers Survey_2-5-2015.docx Report on Pilot Study of Health Care Providers	IC Document
Provider Email Followup Script_2-9-15.docx Script for Email Follow-up to Health Care Providers	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

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
Other-Questionnaire			Annex F_Health care provider questionnaire.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 558

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 50 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	558	558
Annual IC Time Burden (Hours)	297	297
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Report on Pilot Study of Health Care Providers	Rural Community Survey Pilot Study Report_Providers Survey_2-5-2015.docx	02/13/2015
Script for Email Follow-up to Health Care Providers	Provider Email Followup Script_2-9-15.docx	02/13/2015

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