Health Care Provider Survey

Evaluation of the Maternal and Child Health Bureau Pediatric Mental Health Care Access and Screening and Treatment for Maternal Depression and Related Behavioral Disorders Programs Project

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

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.