Information Collection

Physician/PCMH Leader Interview

IC 225251 under ICR 201611-0935-001 · OMB 0935-0236.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 3 Physician/PCMH Leader Interview	Form and Instruction
3 Attachment C: Script for Physician/PCMH Leader Attachment C-SCRIPT-PhysicianPCMH Leader_11Jan2017_FINAL.doc	Form and Instruction
4 Attachment G: Physician/PCMH Leader Interview Protocol Attachment G-Provider Interview Protocol_22Dec2016.docx	Form and Instruction

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 and Instruction	3	Attachment C: Script for Physician/PCMH Leader	Attachment C-SCRIPT-PhysicianPCMH Leader_11Jan2017_FINAL.doc		No		Paper Only
Form and Instruction	4	Attachment G: Physician/PCMH Leader Interview Protocol	Attachment G-Provider Interview Protocol_22Dec2016.docx		No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 176

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

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	176	176
Annual IC Time Burden (Hours)	117	117
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.