Information Collection

Provider Interview Guide

IC 233776 under ICR 202501-0935-001 · OMB 0935-0179.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Provider Interview Guide	Form and Instruction
Form 1 Provider Interview Guide Provider Interview Guide	Form and Instruction
1 Provider Interview Guide Attachment F_Provider Interview Guide_101818.docx	Form and Instruction
1 Provider Interview Guide Attachment F_Provider Interview Guide_101818.docx	Form and Instruction
Fast Track Submission_Provider Interview Guide_101818.doc Fast Track Supporting Statement	IC Document
Fast Track Submission_Provider Interview Guide_101818.doc Fast Track Supporting Statement	IC Document
Supporting Statement_101818.doc Total Overview	IC Document
Supporting Statement_101818.doc Total Overview	IC Document
Cover Page Provider Interview Guide.doc Cover Letter	IC Document
Cover Page Provider Interview Guide.doc Cover Letter	IC Document

IC Title:

Agency IC Tracking Number:

IC Status: Removed

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				No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 18

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: 0 %

table that charts list of burden
	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	-18	18
Annual IC Time Burden (Hours)	-9	9
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Fast Track Supporting Statement		10/31/2018
Total Overview		10/29/2018
Cover Letter		10/29/2018

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

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