Information Collection

Health Professional Impact Survey

IC 267354 under ICR 202404-0906-009 · OMB 0906-0097.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0906-0097 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Health Professional Impact Survey	Form and Instruction
1 Health Professional Impact Survey Attachment B1 - HP Impact Survey_Final.docx	Form and Instruction
1 Health Professional Impact Survey Attachment B1 - HP Impact Survey_Final.docx	Form and Instruction
Attachment B4 - HP Impact Survey Consent_Final.docx Attachment B4 - HP Impact Survey Consent_Final	IC Document
Attachment B4 - HP Impact Survey Consent_Final.docx Attachment B4 - HP Impact Survey Consent_Final	IC Document

IC Title:

Health Professional Impact 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	1	Health Professional Impact Survey	Attachment B1 - HP Impact Survey_Final.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 21,070

Number of Respondents for Small Entity: 21,070

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	42,140	42,140
Annual IC Time Burden (Hours)	7,164	7,164
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachment B4 - HP Impact Survey Consent_Final	Attachment B4 - HP Impact Survey Consent_Final.docx	04/30/2024

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