Information Collection

Social Work and Family Physician Follow-up Survey

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

Documents and Forms

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

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Social Work and Family Physician Follow-up Survey	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Removed

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	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 %

	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

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.