Information Collection

Health Center Provider Survey

IC 222367 under ICR 201607-0920-001 · OMB 0920-1156.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1156 can be found here:

Documents and Forms

Document Name Document Type
Health Center Provider Survey Form and Instruction
Health Center Provider Survey Att 5 Health Center Provider Survey.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Health Center Provider Survey	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

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	NA	Health Center Provider Survey	Att 5 Health Center Provider Survey.docx	NA	No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 126	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions, 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	126	126
Annual IC Time Burden (Hours)	42	42
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.