Information Collection

Healthcare Providers - Pretest

IC 242546 under ICR 202010-0910-009 · OMB 0910-0890.

Documents and Forms

Document Name Document Type
Appendix A - Email Invitation.docx Other-Invitation
Appendix B - Screener.docx Other-Screener

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Healthcare Providers - Pretest	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

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
Other-Invitation			Appendix A - Email Invitation.docx		Yes	Yes	Printable Only
Other-Screener			Appendix B - Screener.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: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	84	84
Annual IC Time Burden (Hours)	4	4
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.