Information Collection

Health Center Provider Survey

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

Documents and Forms

Documents and forms in this information collection
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

IC Title:

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:

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	0920-1156	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 %

table that charts list of burden
	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

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.