Information Collection

Health Center Provider Survey

IC 222367 under ICR 201912-0920-012 · OMB 0920-1156.

Documents and Forms

Document Name Document Type
Form 0920-1156 Health Center Provider Survey Form and Instruction
0920-1156 Health Center Provider Survey Att 4a Health Center Provider Survey final.docx Form and Instruction
0920-1156 Health Center Provider Survey Online Att 4b Health Center Provider Survey Online Version.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Health Center Provider Survey	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

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	0920-1156	Health Center Provider Survey	Att 4a Health Center Provider Survey final.docx		Yes	Yes	Fillable Fileable
Form and Instruction	0920-1156	Health Center Provider Survey Online	Att 4b Health Center Provider Survey Online Version.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 84	Number of Respondents for Small Entity: 0

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

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	84	-42	126
Annual IC Time Burden (Hours)	28	-14	42
Annual IC Cost Burden (Dollars)	0	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.