Information Collection

Interview Protocol for Local Agency Medical Staff

IC 229642 under ICR 201801-0970-001 · OMB 0970-0511.

Documents and Forms

Document Name Document Type
Form 1 Interview Protocol for Local Agency Medical Staff Form and Instruction
1 Interview Protocol for Local Agency Medical Staff Attachment 3 - Interview Protocol for Local Agency Medical Staff Final.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Interview Protocol for Local Agency Medical Staff	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	1	Interview Protocol for Local Agency Medical Staff	Attachment 3 - Interview Protocol for Local Agency Medical Staff Final.docx		Yes	Yes	Fillable Printable

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 14	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	14	14
Annual IC Time Burden (Hours)	14	14
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.