Information Collection

Primary Care Associations (PCAs) Survey Tool Questions

IC 248938 under ICR 202108-0906-001 · OMB 0906-0062.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 5 Primary Care Associations (PCAs) Survey Tool Questions	Form and Instruction
5 PCAs Survey Tool Questions 7-21.pdf FORM 5 - PCAs Survey Tool Questions 7-21.pdf	Form and Instruction
5 PCAs Survey Tool Questions 7-21.pdf FORM 5 - PCAs Survey Tool Questions 7-21.pdf	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

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	5	PCAs Survey Tool Questions 7-21.pdf	FORM 5 - PCAs Survey Tool Questions 7-21.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 52

Number of Respondents for Small Entity: 52

Affected Public: Private Sector

Private Sector: Not-for-profit institutions

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	312	312
Annual IC Time Burden (Hours)	234	234
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.