Information Collection

Physician/Nurse/Practitioner Provider Survey

IC 188680 under ICR 200904-0920-003 · OMB 0920-0740.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0740 can be found here:

Documents and Forms

Document Name Document Type
Attachment3_ProviderSurvey.doc Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Physician/Nurse/Practitioner Provider Survey	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

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
Instruction			Attachment3_ProviderSurvey.doc		Yes	Yes	Printable Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,440	Number of Respondents for Small Entity: 1,440

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 95 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,440	1,440
Annual IC Time Burden (Hours)	480	480
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.