Information Collection

Provider Survey

IC 269817 under ICR 202407-0920-009 · OMB 0920-1438.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1438 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-24CB Provider Survey	Form
Form 0920-24CB Provider Survey	Form
0920-24CB Provider Survey Attachment 04d_Provider Survey_Online_English.docx	Form
0920-24CB Provider Survey Attachment 04d_Provider Survey_Online_English.docx	Form
Attachment 04c_Provider Survey_Paper_English.docx Attachment 04c_Provider Survey_Paper_English	IC Document
Attachment 04c_Provider Survey_Paper_English.docx Attachment 04c_Provider Survey_Paper_English	IC Document
Attachment 04b_Provider Survey_Consent Statement_English.docx Provider Consent	IC Document
Attachment 04b_Provider Survey_Consent Statement_English.docx Provider Consent	IC Document

IC Title:

Provider Survey

Agency IC Tracking Number:

0920-2CB

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	0920-24CB	Provider Survey	Attachment 04d_Provider Survey_Online_English.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 40

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	40	40
Annual IC Time Burden (Hours)	7	7
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachment 04c_Provider Survey_Paper_English	Attachment 04c_Provider Survey_Paper_English.docx	08/05/2024
Provider Consent	Attachment 04b_Provider Survey_Consent Statement_English.docx	08/05/2024

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