Information Collection

Provider Baseline Survey

IC 222568 under ICR 201607-0920-010 · OMB 0920-1160.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Provider Baseline Survey	Form
Baseline survey Att3a_Baseline Screener-Survey_clean.docx	Form
Baseline Screener and Survey Screenshots Att9a_Screenshots_BaselineScreenerSurvey_clean.docx	Form

IC Title:

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	none	Baseline survey	Att3a_Baseline Screener-Survey_clean.docx		Yes	Yes	Fillable Fileable
Form	none	Baseline Screener and Survey Screenshots	Att9a_Screenshots_BaselineScreenerSurvey_clean.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,827

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

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	1,827	1,827
Annual IC Time Burden (Hours)	914	914
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.