Information Collection

17. Attachment S - Patient Toolkit Survey-Provider

IC 268505 under ICR 202406-0935-001 · OMB unassigned.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 17 17. Attachment S - Patient Toolkit Survey-Provider	Form and Instruction
17 Patient ToolKit Survey-Provider Attachment S - Patient Toolkit Survey - Provider.2024_5_24.docx	Form and Instruction
17 Patient ToolKit Survey-Provider Attachment S - Patient Toolkit Survey - Provider.2024_5_24.docx	Form and Instruction

IC Title:

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	17	Patient ToolKit Survey-Provider	Attachment S - Patient Toolkit Survey - Provider.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 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	4,930	4,930
Annual IC Time Burden (Hours)	164	164
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.