Information Collection

Provider Survey

IC 258177 under ICR 202212-0920-004 · OMB 0920-1397.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1397 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Provider Survey	Form and Instruction
Milestone Tracker App Provider Survey (English) H_LTSAE MT Provider Survey_01312023.docx	Form and Instruction
Milestone Tracker App Provider Survey (English) H_LTSAE MT Provider Survey_01312023.docx	Form and Instruction
Milestone Tracker App Provider Survey (Spanish) H.1_LSTAE MT Provider Survey SPANISH_01312023.docx	Form and Instruction
Milestone Tracker App Provider Survey (Spanish) H.1_LSTAE MT Provider Survey SPANISH_01312023.docx	Form and Instruction

IC Title:

Provider Survey

Agency IC Tracking Number:

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	None	Milestone Tracker App Provider Survey (English)	H_LTSAE MT Provider Survey_01312023.docx		Yes	Yes	Fillable Fileable
Form and Instruction	None	Milestone Tracker App Provider Survey (Spanish)	H.1_LSTAE MT Provider Survey SPANISH_01312023.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 100,000

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, 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	100,000	100,000
Annual IC Time Burden (Hours)	8,333	8,333
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.