Information Collection

Health Care Provider Survey

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

Documents and Forms

Document Name Document Type
Form 1-1 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:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	1-1	Attachment B1 - PMHCA Health Care Provider Survey_clean_4-29-2020.docx	Attachment B1 - PMHCA Health Care Provider Survey_clean_4-29-2020.docx	Yes	Yes	Fillable Fileable
Form and Instruction	1-1 Tracked	Attachment B1 - PMHCA Health Care Provider Survey_tracked_4-29-2020.docx	Attachment B1 - PMHCA Health Care Provider Survey_tracked_4-29-2020.docx	Yes	Yes	Fillable Fileable
Form and Instruction	1-2	Attachment B2-MDRBD Health Care Provider Survey_clean_4-29-2020.docx	Attachment B2-MDRBD Health Care Provider Survey_clean_4-29-2020.docx	Yes	Yes	Fillable Fileable
Form and Instruction	1-2 Tracked	Attachment B2-MDRBD Health Care Provider Survey_tracked_4-29-2020.docx	Attachment B2-MDRBD Health Care Provider Survey_tracked_4-29-2020.docx	Yes	Yes	Fillable Fileable

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 %

	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

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.