OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

Provider Survey

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

Documents and Forms
Document Name
Document Type
Form and Instruction
Form and Instruction
IC Document
IC Document
IC Document
IC Document
Information Collection (IC) Details

View Information Collection (IC)

Provider Survey
 
No New
 
Voluntary
 

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

Health Public Health Monitoring

 

74 0
   
State, Local, and Tribal Governments
 
   100 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 74 0 74 0 0 0
Annual IC Time Burden (Hours) 74 0 74 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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.