Primary Care Provider Opt-Out Card

Assessing Problem Areas in Referrals for Chronic Hematologic Malignancies and Developing Interventions to Address Them

Documents and Forms

Document Name Document Type
Att 9_PCP Survey Opt Out Card 092309.doc Other-WORD

Information Collection (IC) Details

IC Title:	Primary Care Provider Opt-Out Card	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
Other-WORD			Att 9_PCP Survey Opt Out Card 092309.doc		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: 09-20-0136, Epidemiologic Studies and Surveillance of Disease Problems	FR Citation: 57 FR 62812

Number of Respondents: 160	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	160	60	100
Annual IC Time Burden (Hours)	5	2	3
Annual IC Cost Burden (Dollars)	0	-308	308

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.