Information Collection

Health Care Providers and Suppliers

IC 184625 under ICR 202403-0990-005 · OMB 0990-0330.

Documents and Forms

Document Name Document Type
Form Appendix B1 Health Care Providers and Suppliers Form and Instruction
Appendix B3 Appellant Climate Survey - Mail (English).docx Other-Appellant Climate Survey Mail
Appendix B3 Appellant Climate Survey - Mail (English).docx Other-Appellant Climate Survey Mail
Appendix B4 Appellant Climate Survey - Mail (Spanish).docx Other-Survey Mail Spanish
Appendix B4 Appellant Climate Survey - Mail (Spanish).docx Other-Survey Mail Spanish
Appendix B5 Appellant Climate Survey - Web (English).docx Other-Survey Web English
Appendix B5 Appellant Climate Survey - Web (English).docx Other-Survey Web English
Appendix B6 Appellant Climate Survey - Web (Spanish).docx Other-Survey Web Spanish
Appendix B6 Appellant Climate Survey - Web (Spanish).docx Other-Survey Web Spanish
Appendix B1 Appellant Climate Survey Telephone English Appendix B1 Appellant Climate Survey - Telephone (English).docx Form and Instruction
Appendix B1 Appellant Climate Survey Telephone English Appendix B1 Appellant Climate Survey - Telephone (English).docx Form and Instruction
Appendix B2 Appellant Climate Survey Telephone Spanish Appendix B2 Appellant Climate Survey - Telephone (Spanish).docx Form and Instruction
Appendix B2 Appellant Climate Survey Telephone Spanish Appendix B2 Appellant Climate Survey - Telephone (Spanish).docx Form and Instruction
Appendix D1 Estimates of Respondent Burden OMHA (1).xlsx Burden Table IC Document
Appendix D1 Estimates of Respondent Burden OMHA (1).xlsx Burden Table IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Health Care Providers and Suppliers	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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	Appendix B1	Appellant Climate Survey Telephone English	Appendix B1 Appellant Climate Survey - Telephone (English).docx	Yes	Yes	Fillable Fileable
Form and Instruction	Appendix B2	Appellant Climate Survey Telephone Spanish	Appendix B2 Appellant Climate Survey - Telephone (Spanish).docx	Yes	Yes	Fillable Fileable
Other-Appellant Climate Survey Mail English			Appendix B3 Appellant Climate Survey - Mail (English).docx	Yes	Yes	Fillable Fileable
Other-Survey Mail Spanish			Appendix B4 Appellant Climate Survey - Mail (Spanish).docx	Yes	Yes	Fillable Fileable
Other-Survey Web English			Appendix B5 Appellant Climate Survey - Web (English).docx	Yes	Yes	Fillable Fileable
Other-Survey Web Spanish			Appendix B6 Appellant Climate Survey - Web (Spanish).docx	Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: General Government

Subfunction: Executive Functions

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 400	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 35 %

	Approved	Previously Approved
Annual Number of Responses for this IC	400	400
Annual IC Time Burden (Hours)	100	100
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Burden Table	Appendix D1 Estimates of Respondent Burden OMHA (1).xlsx	03/20/2024

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