Information Collection

Health Care Provider Survey

IC 239850 under ICR 202206-0906-002 · OMB 0906-0052.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1-1 Health Care Provider Survey	Form and Instruction
Form 1-1 Attachment B1 - PMHCA Health Care Provider Survey_clean_4-29-2020.docx Health Care Provider Survey	Form and Instruction
Form 1-1 Tracked Attachment B1 - PMHCA Health Care Provider Survey_tracked_4-29-2020.docx Health Care Provider Survey	Form and Instruction
Form 1-2 Attachment B2-MDRBD Health Care Provider Survey_clean_4-29-2020.docx Health Care Provider Survey	Form and Instruction
Form 1-2 Tracked Attachment B2-MDRBD Health Care Provider Survey_tracked_4-29-2020.docx Health Care Provider Survey	Form and Instruction
1-1 Attachment B1 - PMHCA Health Care Provider Survey_clean_ Attachment B1 - PMHCA Health Care Provider Survey_clean_4-29-2020.docx	Form and Instruction
1-1 Attachment B1 - PMHCA Health Care Provider Survey_clean_ Attachment B1 - PMHCA Health Care Provider Survey_clean_4-29-2020.docx	Form and Instruction
1-1 Tracked Attachment B1 - PMHCA Health Care Provider Survey_tracke Attachment B1 - PMHCA Health Care Provider Survey_tracked_4-29-2020.docx	Form and Instruction
1-1 Tracked Attachment B1 - PMHCA Health Care Provider Survey_tracke Attachment B1 - PMHCA Health Care Provider Survey_tracked_4-29-2020.docx	Form and Instruction
1-2 Attachment B2-MDRBD Health Care Provider Survey_clean_4- Attachment B2-MDRBD Health Care Provider Survey_clean_4-29-2020.docx	Form and Instruction
1-2 Attachment B2-MDRBD Health Care Provider Survey_clean_4- Attachment B2-MDRBD Health Care Provider Survey_clean_4-29-2020.docx	Form and Instruction
1-2 Tracked Attachment B2-MDRBD Health Care Provider Survey_tracked_ Attachment B2-MDRBD Health Care Provider Survey_tracked_4-29-2020.docx	Form and Instruction
1-2 Tracked Attachment B2-MDRBD Health Care Provider Survey_tracked_ Attachment B2-MDRBD Health Care Provider Survey_tracked_4-29-2020.docx	Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Health Care Provider Survey

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.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	1-1	Yes	Yes	Fillable Fileable
Form and Instruction	1-1 Tracked	Yes	Yes	Fillable Fileable
Form and Instruction	1-2	Yes	Yes	Fillable Fileable
Form and Instruction	1-2 Tracked	Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 13,035

Number of Respondents for Small Entity: 13,035

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	39,105	39,105
Annual IC Time Burden (Hours)	6,648	6,648
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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