Information Collection

Health Professional Survey

IC 271499 under ICR 202505-0906-005 · OMB 0906-0105.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1M Health Professional Survey	Form and Instruction
Form 1M Attachment 1M - Health Professional Survey PMHCA Health Professional Survey	Form and Instruction
Form 1E Attachment 1E - Health Professional Survey MMHSUD Health Professional Survey	Form and Instruction
Form 1E 1E_MCHB_0906-0105_MMHSUD Health Professional Survey_Redline Health Professional Survey	Form and Instruction
Form 1M 1M_MCHB_0906-0105_MCHB_PMHCA Health Professional Survey_Redline Health Professional Survey	Form and Instruction
1M Attachment 1M - Health Professional Survey PMHCA Attachment B1 - Health Professional Survey V3 2021-2023 PMHCA_NON-APPROVED_Clean_9-16-24.docx	Form and Instruction
1M Attachment 1M - Health Professional Survey PMHCA Attachment B1 - Health Professional Survey V3 2021-2023 PMHCA_NON-APPROVED_Clean_9-16-24.docx	Form and Instruction
1E Attachment 1E - Health Professional Survey MMHSUD Attachment B9 - Health Professional Survey V2 2023 MMHSUD_NON-APPROVED_Clean_9-16-24.docx	Form and Instruction
1E Attachment 1E - Health Professional Survey MMHSUD Attachment B9 - Health Professional Survey V2 2023 MMHSUD_NON-APPROVED_Clean_9-16-24.docx	Form and Instruction
1E 1E_MCHB_0906-0105_MMHSUD Health Professional Survey_Redl 1E_MCHB_0906-0105_MMHSUD Health Professional Survey_Redline.docx	Form and Instruction
1E 1E_MCHB_0906-0105_MMHSUD Health Professional Survey_Redl 1E_MCHB_0906-0105_MMHSUD Health Professional Survey_Redline.docx	Form and Instruction
1M 1M_MCHB_0906-0105_MCHB_PMHCA Health Professional Survey_ 1M_MCHB_0906-0105_MCHB_PMHCA Health Professional Survey_Redline.docx	Form and Instruction
1M 1M_MCHB_0906-0105_MCHB_PMHCA Health Professional Survey_ 1M_MCHB_0906-0105_MCHB_PMHCA Health Professional Survey_Redline.docx	Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Health Professional Survey

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	1M	Yes	Yes	Fillable Fileable
Form and Instruction	1E	Yes	Yes	Fillable Fileable
Form and Instruction	1E	Yes	Yes	Fillable Fileable
Form and Instruction	1M	Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 23,256

Number of Respondents for Small Entity: 23,256

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	Previously Approved
Annual Number of Responses for this IC	23,256	23,256
Annual IC Time Burden (Hours)	7,674	7,674
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.

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