Information Collection

Health Center Provider Survey

IC 222386 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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
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

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:

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	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: 24

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	24	24
Annual IC Time Burden (Hours)	8	8
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.