Information Collection

C4P Provider DCE Survey

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

Documents and Forms

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

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	C4P Provider DCE Survey	Agency IC Tracking Number:	0920-22CX

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection 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 %

	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

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.