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⚠️ Notice: This information collection may be referencing outdated material.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

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

Information Collection (IC) Details

View Information Collection (IC)

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:

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 %

	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

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.