Information Collection

Health Care Provider Survey

IC 239850 under ICR 202002-0906-001 · OMB 0906-0052.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0906-0052 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1-1 Health Care Provider Survey	Form and Instruction
1-1 Attachment B1 - PMHCA Health Care Provider Survey_clean_ Attachment B1 - PMHCA Health Care Provider Survey_clean_4-29-2020.docx	Form and Instruction
1-1 Tracked Attachment B1 - PMHCA Health Care Provider Survey_tracke Attachment B1 - PMHCA Health Care Provider Survey_tracked_4-29-2020.docx	Form and Instruction
1-2 Attachment B2-MDRBD Health Care Provider Survey_clean_4- Attachment B2-MDRBD Health Care Provider Survey_clean_4-29-2020.docx	Form and Instruction
1-2 Tracked Attachment B2-MDRBD Health Care Provider Survey_tracked_ Attachment B2-MDRBD Health Care Provider Survey_tracked_4-29-2020.docx	Form and Instruction

IC Title:

Health Care Provider Survey

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	1-1	Attachment B1 - PMHCA Health Care Provider Survey_clean_4-29-2020.docx	Attachment B1 - PMHCA Health Care Provider Survey_clean_4-29-2020.docx	Yes	Yes	Fillable Fileable
Form and Instruction	1-1 Tracked	Attachment B1 - PMHCA Health Care Provider Survey_tracked_4-29-2020.docx	Attachment B1 - PMHCA Health Care Provider Survey_tracked_4-29-2020.docx	Yes	Yes	Fillable Fileable
Form and Instruction	1-2	Attachment B2-MDRBD Health Care Provider Survey_clean_4-29-2020.docx	Attachment B2-MDRBD Health Care Provider Survey_clean_4-29-2020.docx	Yes	Yes	Fillable Fileable
Form and Instruction	1-2 Tracked	Attachment B2-MDRBD Health Care Provider Survey_tracked_4-29-2020.docx	Attachment B2-MDRBD Health Care Provider Survey_tracked_4-29-2020.docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 13,035

Number of Respondents for Small Entity: 13,035

Affected Public: Private Sector

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

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	39,105	39,105
Annual IC Time Burden (Hours)	6,648	6,648
Annual IC Cost Burden (Dollars)	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.