Information Collection

Practitioner Reporting Form

IC 223711 under ICR 201609-0930-001 · OMB 0930-0234.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0930-0234 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Practitioner Repor Practitioner Reporting Form	Form and Instruction
Practitioner Repor Practitioner Reporting Form Attachment I - Practitioner Reporting Form final.docx	Form and Instruction
275 waiver annual report.pdf Waiver Annual Report	IC Document

IC Title:

Practitioner Reporting Form

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 and Instruction	Practitioner Reporting Form	Practitioner Reporting Form	Attachment I - Practitioner Reporting Form final.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,350

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

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	1,350	1,350
Annual IC Time Burden (Hours)	4,050	4,050
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Waiver Annual Report	275 waiver annual report.pdf	01/09/2017

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.