Information Collection

Provider Survey

IC 269817 under ICR 202505-0920-004 · OMB 0920-1438.

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 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: Unchanged

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				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	Previously Approved
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		08/05/2024
Provider Consent		08/05/2024

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

Something went wrong when downloading this file. If you have any questions, please send an email to [email protected].