Information Collection

Health Professional Impact Survey

IC 267354 under ICR 202508-0906-004 · OMB unassigned.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Health Professional Impact Survey Health Professional Impact Survey	Form and Instruction
Form 1 Health Professional Impact Survey (Michigan Grantee Only) Health Professional Impact Survey	Form and Instruction
1 Health Professional Impact Survey Attachment B1 - HP Impact Survey_Final.docx	Form and Instruction
1 Health Professional Impact Survey (Michigan Grantee Only MI PMHCA HPI Survey_Tracked 8-19-25.docx	Form and Instruction
Attachment B4 - HP Impact Survey Consent_Final.docx Attachment B4 - HP Impact Survey Consent_Final	IC Document

IC Title:

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.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	1				Yes	Yes	Fillable Fileable
Form and Instruction	1				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 21,070

Number of Respondents for Small Entity: 21,070

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	42,140	42,140
Annual IC Time Burden (Hours)	7,164	7,164
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachment B4 - HP Impact Survey Consent_Final		04/30/2024

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

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