16. Attachment R - Provider Characteristics Form

Implementation and Testing of Diagnostic Safety Resources

Documents and Forms

Document Name Document Type
Form 16 16. Attachment R - Provider Characteristics Form Form and Instruction
16 Toolkit for Engaging Patients Provider Demographic Surve Attachment R - Provider Characteristics Form.2024_5_24.docx Form and Instruction
16 Toolkit for Engaging Patients Provider Demographic Surve Attachment R - Provider Characteristics Form.2024_5_24.docx Form and Instruction

Information Collection (IC) Details

IC Title:	16. Attachment R - Provider Characteristics Form	Agency IC Tracking Number:

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	16	Toolkit for Engaging Patients Provider Demographic Survey	Attachment R - Provider Characteristics Form.2024_5_24.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 986	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: 90 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	986	986
Annual IC Time Burden (Hours)	16	16
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.