View Information Collection (IC)

View Information Collection (IC)

View Information Collection (IC)

IC Title:	Provider Survey	Agency IC Tracking Number:	0920-2CB

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	0920-24CB	Provider Survey	Attachment 04d_Provider Survey_Online_English.docx		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: 40	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

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	40	0	40	0	0	0
Annual IC Time Burden (Hours)	7	0	7	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
Attachment 04c_Provider Survey_Paper_English	Attachment 04c_Provider Survey_Paper_English.docx	08/05/2024
Provider Consent	Attachment 04b_Provider Survey_Consent Statement_English.docx	08/05/2024

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