Information Collection

Health Care Providers and Suppliers

IC 184625 under ICR 202103-0990-004 · OMB 0990-0330.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0990-0330 can be found here:

Documents and Forms

Document Name Document Type
Appendix B1 Appellant Climate Survey - Telephone (English).docx Other-survey
Appendix B1 Appellant Climate Survey - Telephone (English).docx Other-survey
Appendix B2 Appellant Climate Survey - Telephone (Spanish).docx Other-form
Appendix B2 Appellant Climate Survey - Telephone (Spanish).docx Other-form
Appendix B3 Appellant Climate Survey - Mail (English).docx Other-Survey
Appendix B3 Appellant Climate Survey - Mail (English).docx Other-Survey
Appendix B4 Appellant Climate Survey - Mail (Spanish).docx Other-survey
Appendix B4 Appellant Climate Survey - Mail (Spanish).docx Other-survey
Appendix B5 Appellant Climate Survey - Web (English).docx Other-survey
Appendix B5 Appellant Climate Survey - Web (English).docx Other-survey
Appendix B6 Appellant Climate Survey - Web (Spanish).docx Other-survey
Appendix B6 Appellant Climate Survey - Web (Spanish).docx Other-survey
Appendix D1 Estimates of Respondent Burden OMHA.xlsx Estimates of Respondents Burdens IC Document
Appendix D1 Estimates of Respondent Burden OMHA.xlsx Estimates of Respondents Burdens IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Health Care Providers and Suppliers	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-survey	Appendix B1 Appellant Climate Survey - Telephone (English).docx	Yes	Yes	Fillable Fileable
Other-form	Appendix B2 Appellant Climate Survey - Telephone (Spanish).docx	No		Paper Only
Other-Survey	Appendix B3 Appellant Climate Survey - Mail (English).docx	No		Paper Only
Other-survey	Appendix B4 Appellant Climate Survey - Mail (Spanish).docx	No		Paper Only
Other-survey	Appendix B5 Appellant Climate Survey - Web (English).docx	Yes	Yes	Fillable Fileable
Other-survey	Appendix B6 Appellant Climate Survey - Web (Spanish).docx	Yes	Yes	Fillable Fileable

Line of Business: General Government

Subfunction: Executive Functions

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 400	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	400	200	200
Annual IC Time Burden (Hours)	100	50	50
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Estimates of Respondents Burdens	Appendix D1 Estimates of Respondent Burden OMHA.xlsx	03/15/2021

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