Information Collection

Card survey (clinician)

IC 241469 under ICR 202004-0935-004 · OMB 0935-0253.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0935-0253 can be found here:

Documents and Forms

Document Name Document Type
Form 2 Card survey (clinician) Form and Instruction
2 Card survey (clinician) Clinician Card Survey_Clean_3.18.2020.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Card survey (clinician)	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	2	Card survey (clinician)	Clinician Card Survey_Clean_3.18.2020.docx		No		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: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	12,000	12,000
Annual IC Time Burden (Hours)	200	200
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.