Information Collection

Project Staff Communication Form - medical providers

IC 220127 under ICR 201602-0920-007 · OMB 0920-1019.

Documents and Forms

Document Name Document Type
Project Staff Communication Form - medical providers Form
Staff Communication Form - medical providers Att 11b_Staff Communication Form for Medical Providers.docx Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Project Staff Communication Form - medical providers	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	none	Staff Communication Form - medical providers	Att 11b_Staff Communication Form for Medical Providers.docx		No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 40	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	80	80
Annual IC Time Burden (Hours)	40	40
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.