Information Collection

Online Survey - Z-CAN Physician

IC 225610 under ICR 201702-0920-003 · OMB 0920-1164.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Online Survey - Z-CAN Physician	Form and Instruction
Online Survey - Physician English Att N-1 Online Survey_Physicians (Eng).docx	Form and Instruction
Online Survey Physician Spanish/Screenshot Att N-2 Screen shots_Online survey_Physicians (Span).pdf	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	NA	Online Survey - Physician English	Att N-1 Online Survey_Physicians (Eng).docx	NA	Yes	Yes	Fillable Fileable
Form and Instruction	NA	Online Survey Physician Spanish/Screenshot	Att N-2 Screen shots_Online survey_Physicians (Span).pdf	NA	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: 09-20-0136, Epidemiologic Studies and Surveillance of Disease Problems

FR Citation: 57 FR 62812

Number of Respondents: 163

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

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	163	163
Annual IC Time Burden (Hours)	41	41
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.