Information Collection

C4P Provider DCE Survey

IC 256139 under ICR 202209-0920-019 · OMB 0920-1400.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920 C4P Provider DCE Survey	Form and Instruction
0920 C4P Provider DCE Survey Att 8 Provider DCE Survey.docx survey.rti.org/SE/1/ProviderSurveyDev	Form and Instruction
0920 C4P Provider DCE Survey Att 8 Provider DCE Survey.docx survey.rti.org/SE/1/ProviderSurveyDev	Form and Instruction
Att 8a Provider DCE Survey Screenshots.docx C4P Provider DCE Survey Screenshots	IC Document
Att 8a Provider DCE Survey Screenshots.docx C4P Provider DCE Survey Screenshots	IC Document

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	C4P Provider DCE Survey	Att 8 Provider DCE Survey.docx	https://survey.rti.org/SE/1/ProviderSurveyDev	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 230

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Not-for-profit institutions

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	230	230
Annual IC Time Burden (Hours)	77	77
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
C4P Provider DCE Survey Screenshots	Att 8a Provider DCE Survey Screenshots.docx	09/26/2022

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