Information Collection

Users, Non-Users, Entities Respondents

IC 207742 under ICR 202102-0915-002 · OMB 0915-0366.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Users, Non-Users, Entities Respondents	Form and Instruction
1 Users Non-Users Entites survey screenshots.pdf FORM Attachment 12 Users Non-Users Entites survey screenshots.pdf	Form and Instruction
1 Users Non-Users Entites survey screenshots.pdf FORM Attachment 12 Users Non-Users Entites survey screenshots.pdf	Form and Instruction
Attachment 10 Entities survey codebook 1-21.pdf Attachment 10 Entities survey codebook 1-21	IC Document
Attachment 10 Entities survey codebook 1-21.pdf Attachment 10 Entities survey codebook 1-21	IC Document
Attachment 14 Email to entities.docx Attachment 14 Email to entities	IC Document
Attachment 14 Email to entities.docx Attachment 14 Email to entities	IC Document
Attachment 15 Telephone non users.docx Attachment 15 Telephone non users	IC Document
Attachment 15 Telephone non users.docx Attachment 15 Telephone non users	IC Document
1 Entities_Flowchart.pdf 1 Entities_Flowchart	IC Document
1 Entities_Flowchart.pdf 1 Entities_Flowchart	IC Document
1 Welcome Page.docx 1 Welcome Page	IC Document
1 Welcome Page.docx 1 Welcome Page	IC Document
2 Demographics.docx 2 Demographics	IC Document
2 Demographics.docx 2 Demographics	IC Document
3 Demographics - Hospitals.docx 3 Demographics - Hospitals	IC Document
3 Demographics - Hospitals.docx 3 Demographics - Hospitals	IC Document
4 Demographics - Several entities.docx 4 Demographics - Several entities	IC Document
4 Demographics - Several entities.docx 4 Demographics - Several entities	IC Document
5 Demographics - Professional society.docx 5 Demographics - Professional society	IC Document
5 Demographics - Professional society.docx 5 Demographics - Professional society	IC Document
6 Demographics - State licensing certification.docx 6 Demographics - State licensing certification	IC Document
6 Demographics - State licensing certification.docx 6 Demographics - State licensing certification	IC Document
7 Demographics - Prosecutor.docx 7 Demographics - Prosecutor	IC Document
7 Demographics - Prosecutor.docx 7 Demographics - Prosecutor	IC Document
8 Query - Intro.docx 8 Query - Intro	IC Document
8 Query - Intro.docx 8 Query - Intro	IC Document
9 Query - Agent.docx 9 Query - Agent	IC Document
9 Query - Agent.docx 9 Query - Agent	IC Document
10 Query - Legal requirement.docx 10 Query - Legal requirement	IC Document
10 Query - Legal requirement.docx 10 Query - Legal requirement	IC Document
11 Query - Experiences.docx 11 Query - Experiences	IC Document
11 Query - Experiences.docx 11 Query - Experiences	IC Document
12 Query - Satisfaction.docx 12 Query - Satisfaction	IC Document
12 Query - Satisfaction.docx 12 Query - Satisfaction	IC Document
13 Perceptions.docx 13 Perceptions	IC Document
13 Perceptions.docx 13 Perceptions	IC Document
14 Matched responses - Intro.docx 14 Matched responses - Intro	IC Document
14 Matched responses - Intro.docx 14 Matched responses - Intro	IC Document
15 Matched responses - Details.docx 15 Matched responses - Details	IC Document
15 Matched responses - Details.docx 15 Matched responses - Details	IC Document
16 Reports - Intro.docx 16 Reports - Intro	IC Document
16 Reports - Intro.docx 16 Reports - Intro	IC Document
17 AAR - Agent.docx 17 AAR - Agent	IC Document
17 AAR - Agent.docx 17 AAR - Agent	IC Document
18 AAR - Experiences.docx 18 AAR - Experiences	IC Document
18 AAR - Experiences.docx 18 AAR - Experiences	IC Document
19 Report information.docx 19 Report information	IC Document
19 Report information.docx 19 Report information	IC Document
20 NPDB Awareness.docx 20 NPDB Awareness	IC Document
20 NPDB Awareness.docx 20 NPDB Awareness	IC Document
21 Satisfaction with products and services.docx 21 Satisfaction with products and services	IC Document
21 Satisfaction with products and services.docx 21 Satisfaction with products and services	IC Document
22 NPDB HIPDB Merger.docx 22 NPDB HIPDB Merger	IC Document
22 NPDB HIPDB Merger.docx 22 NPDB HIPDB Merger	IC Document
23 Attestation Initiative.docx 23 Attestation Initiative	IC Document
23 Attestation Initiative.docx 23 Attestation Initiative	IC Document
24 Authorized agents - Query intro.docx 24 Authorized agents - Query intro	IC Document
24 Authorized agents - Query intro.docx 24 Authorized agents - Query intro	IC Document
25 Authorized agents - Query demographics.docx 25 Authorized agents - Query demographics	IC Document
25 Authorized agents - Query demographics.docx 25 Authorized agents - Query demographics	IC Document
26 Authorized agents - Query experiences.docx 26 Authorized agents - Query experiences	IC Document
26 Authorized agents - Query experiences.docx 26 Authorized agents - Query experiences	IC Document
27 Authorized agents - Reports intro.docx 27 Authorized agents - Reports intro	IC Document
27 Authorized agents - Reports intro.docx 27 Authorized agents - Reports intro	IC Document
28 Authorized agents - Report demographics.docx 28 Authorized agents - Report demographics	IC Document
28 Authorized agents - Report demographics.docx 28 Authorized agents - Report demographics	IC Document
29 Authorized agents - Report experiences.docx 29 Authorized agents - Report experiences	IC Document
29 Authorized agents - Report experiences.docx 29 Authorized agents - Report experiences	IC Document
30 Attestation - Authorized Agents.docx 30 Attestation - Authorized Agents	IC Document
30 Attestation - Authorized Agents.docx 30 Attestation - Authorized Agents	IC Document
31 MMPR - Intro.docx 31 MMPR - Intro	IC Document
31 MMPR - Intro.docx 31 MMPR - Intro	IC Document
32 MMPR - Reason for non-reporting.docx 32 MMPR - Reason for non-reporting	IC Document
32 MMPR - Reason for non-reporting.docx 32 MMPR - Reason for non-reporting	IC Document
33 MMPR - Experiences.docx 33 MMPR - Experiences	IC Document
33 MMPR - Experiences.docx 33 MMPR - Experiences	IC Document
34 COVID 19.docx 34 COVID 19	IC Document
34 COVID 19.docx 34 COVID 19	IC Document
35 JOCR - Experiences.docx 35 JOCR - Experiences	IC Document
35 JOCR - Experiences.docx 35 JOCR - Experiences	IC Document
36 End comments.docx 36 End comments	IC Document
36 End comments.docx 36 End comments	IC Document
37 Software services.docx 37 Software services	IC Document
37 Software services.docx 37 Software services	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Users, Non-Users, Entities Respondents

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	1	Users Non-Users Entites survey screenshots.pdf	FORM Attachment 12 Users Non-Users Entites survey screenshots.pdf		Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 15,000

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

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	15,000	15,000
Annual IC Time Burden (Hours)	3,750	3,750
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachment 10 Entities survey codebook 1-21	Attachment 10 Entities survey codebook 1-21.pdf	02/11/2021
Attachment 14 Email to entities	Attachment 14 Email to entities.docx	02/11/2021
Attachment 15 Telephone non users	Attachment 15 Telephone non users.docx	02/11/2021
1 Entities_Flowchart	1 Entities_Flowchart.pdf	02/11/2021
1 Welcome Page	1 Welcome Page.docx	02/11/2021
2 Demographics	2 Demographics.docx	02/11/2021
3 Demographics - Hospitals	3 Demographics - Hospitals.docx	02/11/2021
4 Demographics - Several entities	4 Demographics - Several entities.docx	02/11/2021
5 Demographics - Professional society	5 Demographics - Professional society.docx	02/11/2021
6 Demographics - State licensing certification	6 Demographics - State licensing certification.docx	02/11/2021
7 Demographics - Prosecutor	7 Demographics - Prosecutor.docx	02/11/2021
8 Query - Intro	8 Query - Intro.docx	02/11/2021
9 Query - Agent	9 Query - Agent.docx	02/11/2021
10 Query - Legal requirement	10 Query - Legal requirement.docx	02/11/2021
11 Query - Experiences	11 Query - Experiences.docx	02/11/2021
12 Query - Satisfaction	12 Query - Satisfaction.docx	02/11/2021
13 Perceptions	13 Perceptions.docx	02/11/2021
14 Matched responses - Intro	14 Matched responses - Intro.docx	02/11/2021
15 Matched responses - Details	15 Matched responses - Details.docx	02/11/2021
16 Reports - Intro	16 Reports - Intro.docx	02/11/2021
17 AAR - Agent	17 AAR - Agent.docx	02/11/2021
18 AAR - Experiences	18 AAR - Experiences.docx	02/11/2021
19 Report information	19 Report information.docx	02/11/2021
20 NPDB Awareness	20 NPDB Awareness.docx	02/11/2021
21 Satisfaction with products and services	21 Satisfaction with products and services.docx	02/11/2021
22 NPDB HIPDB Merger	22 NPDB HIPDB Merger.docx	02/11/2021
23 Attestation Initiative	23 Attestation Initiative.docx	02/11/2021
24 Authorized agents - Query intro	24 Authorized agents - Query intro.docx	02/11/2021
25 Authorized agents - Query demographics	25 Authorized agents - Query demographics.docx	02/11/2021
26 Authorized agents - Query experiences	26 Authorized agents - Query experiences.docx	02/11/2021
27 Authorized agents - Reports intro	27 Authorized agents - Reports intro.docx	02/11/2021
28 Authorized agents - Report demographics	28 Authorized agents - Report demographics.docx	02/11/2021
29 Authorized agents - Report experiences	29 Authorized agents - Report experiences.docx	02/11/2021
30 Attestation - Authorized Agents	30 Attestation - Authorized Agents.docx	02/11/2021
31 MMPR - Intro	31 MMPR - Intro.docx	02/11/2021
32 MMPR - Reason for non-reporting	32 MMPR - Reason for non-reporting.docx	02/11/2021
33 MMPR - Experiences	33 MMPR - Experiences.docx	02/11/2021
34 COVID 19	34 COVID 19.docx	02/11/2021
35 JOCR - Experiences	35 JOCR - Experiences.docx	02/11/2021
36 End comments	36 End comments.docx	02/11/2021
37 Software services	37 Software services.docx	02/11/2021

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