Information Collection

Provider Interview Protocol

IC 236870 under ICR 201907-0906-001 · OMB 0906-0046.

Documents and Forms

Document Name Document Type
Form 1 Provider Interview Protocol Form and Instruction
1 B1 Provder Interview Protocols Attachment B1 - Provider_Interview_Protocols.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Provider Interview Protocol	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	B1 Provder Interview Protocols	Attachment B1 - Provider_Interview_Protocols.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 100	Number of Respondents for Small Entity: 10

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	100	100
Annual IC Time Burden (Hours)	100	100
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.