Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
ACPI New 11667 5834 0 Form and Instruction 0920-0234 ACPI
Advance Practice ACPI New 21667 10834 0 Form and Instruction 0920-0234 Advanced Practice ACPI
Contact Tracing New 21667 3611 0 Form and Instruction 0920-0234 Tracing Questionnaire
Contact Tracing New 11667 1945 0 Form and Instruction 0920-0234 Tracing Questionnaire
HC Facility Interview 2022 Modified 73 55 0 Form and Instruction 0920-0234 Health Center (HC) Facility Interview
HC Facility Interview (2023-2025) Modified 300 225 0 Form and Instruction 0920-0234 HC Facility Interview questionnaire
PFI (2023- 2025) Modified 3000 2250 0 Form and Instruction 0920-0234 PFI (2023-2025)
Physician Induction Interview (2020) Removed 0 0 0 Form and Instruction 0920-0234 Att P2- 2021 Census Reinterview Instrument
Physician Induction Interview (2021-2023) Removed 0 0 0 Form and Instruction 0920-0234 Physician Induction Interview (2021-2023)
Prepare and transmit EHR for Visit Data (quarterly) (2022) New 12000 12000 0 Form and Instruction 0920-0234 Attachment O1_NAMCS EHR Record Pulling Burden
Form and Instruction 0920-0234 Attachment O2_NAMCS EHR Record Pulling Burden
Prepare and transmit EHR for Visit Data (quarterly) (2022) Modified 132 132 0 Form and Instruction 0920-0234 Attachment O1_NAMCS EHR Record Pulling Burden
Prepare and transmit EHR for Visit Data (quarterly) (2023-2025) New 800 800 0 Form and Instruction 0920-0234 Attachment O1_NAMCS EHR Record Pulling Burden
Provider Induction Interview (2020) Removed 0 0 0 Form and Instruction 0920-0234 HC Facility Induction Interview (2020)
Pulling and Refiling Medical Record Forms EHR Onboarding) (2021-2023) Removed 0 0 0 Form and Instruction 0920-2034 EHR Pulling Records Burden
Pulling, re-filing medical record forms (FR abstracts) (2020) Removed 0 0 0 Form 0920-0234 Att R- 2021 EHR Pulling Records Burden
Form and Instruction 0920-0234 PRF Burden Abstract
Pulling, re-filing medical record forms (FR abstracts) (2021-2023) Removed 0 0 0 Form and Instruction 0920-0234 Att C2- 2021 NAMCS-1 Traditional Physician
Reinterview Study (2021-2023) Removed 0 0 0 Form and Instruction 0920-0234 Reinterview Study (2021-2023)
Reinterview Study - Traditional Physician and CHC Staff Removed 0 0 0 Form 0920-0234 2020 Reinterview Instrument
Set-up Fee Questionnaire New 33 8 0 Form and Instruction 0920-0234 Attachment J_Set-up Fee Questionnaire
Set-up Fee Questionnaire (2023-2025) New 200 50 0 Form and Instruction 0920-0234 Attachment J_Set-up Fee Questionnaire
Total burden requested under this ICR: 83206 37744 0  
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