Information Collection

Attachment 1 -- Evaluation Provider Survey

IC 244072 under ICR 202010-0935-001 · OMB 0935-0257.

Documents and Forms

Document Name Document Type
Form 1 Attachment 1 -- Evaluation Provider Survey Form and Instruction
1 Attachment 1 -- Evaluation Provider Survey Attachment 1_Evaluation Provider Survey.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Attachment 1 -- Evaluation Provider Survey	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	1	Attachment 1 -- Evaluation Provider Survey	Attachment 1_Evaluation Provider Survey.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 60	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: 50 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	60	60
Annual IC Time Burden (Hours)	15	15
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
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Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.