Information Collection

Medication-Assisted Treatment (MAT) Providers & PrEP Providers Survey

IC 235443 under ICR 202201-0917-001 · OMB 0917-0036.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0917-0036 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 87 Medication-Assisted Treatment (MAT) Providers & PrEP Providers Survey	Form and Instruction
87 MAT Provider Survey MAT Provider Survey Draft 3-18-19.docx	Form and Instruction
87 MAT Provider Survey MAT Provider Survey Draft 3-18-19.docx	Form and Instruction
87-1 PrEP Questionnaire PrEP Questionnaire Draft 3-18-19.docx	Form and Instruction
87-1 PrEP Questionnaire PrEP Questionnaire Draft 3-18-19.docx	Form and Instruction
2015 Clearance Submission Template - MAT-PrEP Provider Surveys.doc MAT-PrEP Provider Surveys	IC Document
2015 Clearance Submission Template - MAT-PrEP Provider Surveys.doc MAT-PrEP Provider Surveys	IC Document

IC Title:

Medication-Assisted Treatment (MAT) Providers & PrEP Providers Survey

Agency IC Tracking Number:

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	87	MAT Provider Survey	MAT Provider Survey Draft 3-18-19.docx		Yes	Yes	Fillable Fileable
Form and Instruction	87-1	PrEP Questionnaire	PrEP Questionnaire Draft 3-18-19.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 125

Number of Respondents for Small Entity: 0

Affected Public: Federal Government

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Previously Approved
Annual Number of Responses for this IC	125	125
Annual IC Time Burden (Hours)	19	19
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
MAT-PrEP Provider Surveys	2015 Clearance Submission Template - MAT-PrEP Provider Surveys.doc	03/21/2019

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