Information Collection

Provider Survey

IC 222120 under ICR 201606-0930-004 · OMB 0930-0366.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Provider Survey Provider Survey	Form and Instruction
Provider Survey Provider Survey Attachment 5 Provider Survey.docx	Form and Instruction
Attachment 1 Evaluation Questions.docx Evaluation Questions	IC Document
Attachment 7 Interview Guides Supporting Documents.docx Interview Guide Supporting Documents	IC Document
Attachment 8 Provider Survey Supporting Documents.doc Provider Survey Supporting Documents	IC Document
Attachment 9 Provider Survey table shells.docx Provider Survey Table Shells	IC Document

IC Title:

Provider Survey

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

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 Survey	Provider Survey	Attachment 5 Provider Survey.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 74

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
Annual Number of Responses for this IC	74	74
Annual IC Time Burden (Hours)	74	74
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Evaluation Questions	Attachment 1 Evaluation Questions.docx	06/23/2016
Interview Guide Supporting Documents	Attachment 7 Interview Guides Supporting Documents.docx	06/23/2016
Provider Survey Supporting Documents	Attachment 8 Provider Survey Supporting Documents.doc	06/23/2016
Provider Survey Table Shells	Attachment 9 Provider Survey table shells.docx	06/23/2016

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