Information Collection

Provider Screening

IC 263492 under ICR 202602-0920-002 · OMB 0920-1428.

Documents and Forms

Document Name Document Type
Form 0920-22FZ Att 4g_Provider Screener Provider Screening Form and Instruction
0920-22FZ Att 4g_Provider Screener Att 4g_Provider Screener.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Provider Screening	Agency IC Tracking Number:	0920-22FZ

Is this a Common Form? Yes		IC Status: Unchanged

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	0920-22FZ	Att 4g_Provider Screener	Att 4g_Provider Screener.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 14	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	14	14
Annual IC Time Burden (Hours)	3	3
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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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