Information Collection

Card survey (clinician)

IC 241469 under ICR 202107-0935-004 · OMB 0935-0253.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 2 Card survey (clinician)	Form and Instruction
Form 2 Card survey (clinician) Card survey (clinician)	Form and Instruction
2 Card survey (clinician) Clinician Card Survey_Clean_3.18.2020.docx	Form and Instruction
2 Card survey (clinician) Clinician Card Survey_Clean_3.18.2020.docx	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

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	2				No		Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 100

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	12,000	12,000
Annual IC Time Burden (Hours)	200	200
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.

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