View Information Collection (IC)

View Information Collection (IC)

View Information Collection (IC)

IC Title:	Separately billing doctors questionnaire	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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	Form #1				Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 10,800	Number of Respondents for Small Entity: 0

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

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to New Statute	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA	Previously Approved
Annual Number of Responses for this IC	21,600	0	-3,300	0	0	24,900
Annual IC Time Burden (Hours)	1,080	0	-165	0	0	1,245
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
Attachment 38 -- MPC SBD Respondent Materials - Fax Version		09/24/2012
Attachment 39 -- MPC SBD Respondent Materials - Phone Version		09/24/2012

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

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