Information Collection

Provider Screening & Consent

IC 256138 under ICR 202209-0920-019 · OMB 0920-1400.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920 Provider Screening & Consent	Form and Instruction
0920 Provider Screening & Consent Att 6 Provider Screening & Consent.docx	Form and Instruction
0920 Provider Screening & Consent Att 6 Provider Screening & Consent.docx	Form and Instruction

IC Title:

Agency IC Tracking Number:

0920-22CX

Is this a Common Form? No

IC Status: New

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	0920	Provider Screening & Consent	Att 6 Provider Screening & Consent.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,150

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

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	1,150	1,150
Annual IC Time Burden (Hours)	192	192
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.