Information Collection

Providers –e-RX Deployment Survey

IC 216513 under ICR 201804-0917-001 · OMB 0917-0036.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0917-0036 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0917-0036 Providers –e-RX Deployment Survey	Form and Instruction
0917-0036 Providers - e-RX Deployment Survey Providers - eRX Deployment.pdf	Form and Instruction
OMB No. 0917-0036-35, e-Prescribing End User Survey.doc OMB No. 0917-0036, Mini-Supporting Statement for Provider –e-RX Deployment Survey	IC Document

IC Title:

Providers âe-RX Deployment Survey

Agency IC Tracking Number:

IC Status: Removed

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	0917-0036	Providers - e-RX Deployment Survey	Providers - eRX Deployment.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 300

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	-300	300
Annual IC Time Burden (Hours)	-25	25
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
OMB No. 0917-0036, Mini-Supporting Statement for Provider âe-RX Deployment Survey	OMB No. 0917-0036-35, e-Prescribing End User Survey.doc	05/08/2015

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