View Information Collection (IC)

View Information Collection (IC)

View Information Collection (IC)

IC Title:	C4P Provider DCE Survey	Agency IC Tracking Number:	0920-22CX

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
Form and Instruction	0920			https://survey.rti.org/SE/1/ProviderSurveyDev	Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 230	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	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	230	0	230	0	0	0
Annual IC Time Burden (Hours)	77	0	77	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
C4P Provider DCE Survey Screenshots		09/26/2022

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

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