Information Collection

Social Work and Family Physician Follow-up Survey

IC 220426 under ICR 202102-0920-003 · OMB 0920-1129.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Social Work and Family Physician Follow-up Survey	Form
Social Work and Family Physician Follow-up Survey T3 Social Work & Family Physicians 6 Month Follow Up Survey.pdf	Form
Social Work and Family Physician Follow-up Survey T3 Social Work & Family Physicians 6 Month Follow Up Survey.pdf	Form

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Removed

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	none	Social Work and Family Physician Follow-up Survey	T3 Social Work & Family Physicians 6 Month Follow Up Survey.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,167

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	-1,167	1,167
Annual IC Time Burden (Hours)	-156	156
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.