Information Collection

ADSC Provider Questionnaire

IC 231011 under ICR 201803-0920-001 · OMB 0920-0943.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0943 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-0943 ADSC Provider Questionnaire	Form and Instruction
0920-0943 ADSC Provider Questionnaire Attachment C-1 011018.docx	Form and Instruction

IC Title:

ADSC Provider Questionnaire

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	0920-0943	ADSC Provider Questionnaire	Attachment C-1 011018.docx	NA	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: Health Resources Utilization Statistics

FR Citation: 49 FR 37697

Number of Respondents: 1,419

Number of Respondents for Small Entity: 397

Affected Public: Private Sector

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

Percentage of Respondents Reporting Electronically: 30 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,419	1,419
Annual IC Time Burden (Hours)	710	710
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.