Information Collection

Service Provider Feedback Form

IC 201612 under ICR 202601-0930-001 · OMB 0930-0270.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Service Provider F Service Provider Feedback Form	Form and Instruction
Form 0930-0270 DTAC-CCP 0930-0270 DTAC-CCP_Service Provider Feedback Form Service Provider Feedback Form	Form and Instruction
Service Provider F Service Provider Feedback Form Attach G dtac-ccp-toolkit-service-provider-feedback-form.pdf	Form and Instruction
0930-0270 DTAC-CCP 0930-0270 DTAC-CCP_Service Provider Feedback Form 0930-0270 DTAC-CCPTkit-ProviderSurvey-Final.pdf	Form and Instruction

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	0930-0270 DTAC-CCP_Service Provider Feedback Form				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: Service Provider Feedback Form

FR Citation: 75 FR 28264

Number of Respondents: 400

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	400	400
Annual IC Time Burden (Hours)	120	120
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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