Information Collection

Provider Baseline Survey

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

Documents and Forms

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

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Provider Baseline Survey	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection 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 %

	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

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.