Information Collection

Family Medicine Evaluation

IC 220422 under ICR 201707-0920-006 · OMB 0920-1129.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1129 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Family Medicine Evaluation	Form
Family Medicine Evaluation T4 Family Medicine Evaluation Questions Addendum for Practice or Individual Provider.pdf	Form
J4 Family Medicine Evaluation Questions Addendum for Practice or Individual Provider.doc Family Medicine Evaluation	IC Document

IC Title:

Family Medicine Evaluation

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

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	none	Family Medicine Evaluation	T4 Family Medicine Evaluation Questions Addendum for Practice or Individual Provider.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 62

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	62	62
Annual IC Time Burden (Hours)	8	8
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Family Medicine Evaluation	J4 Family Medicine Evaluation Questions Addendum for Practice or Individual Provider.doc	03/02/2016

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