Health Center Provider Survey

Performance Monitoring of “Working with Publicly Funded Health Centers to Reduce Teen Pregnancy among Youth from Vulnerable Populations

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

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

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 16	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	16	-8	24
Annual IC Time Burden (Hours)	6	-2	8
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.