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Practice Managers Form A Screener Administered on Paper
Survey of Medical Care Providers for the Evaluation of the Regional Extension Center (REC) Program
OMB: 0955-0015
IC ID: 209866
OMB.report
HHS/ONC
OMB 0955-0015
ICR 201407-0955-002
IC 209866
( )
Documents and Forms
Document Name
Document Type
20745_Form A Screener Administered on Paper 120513.docx
Other-screener
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Practice Managers Form A Screener Administered on Paper
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
Unchanged
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-screener
20745_Form A Screener Administered on Paper 120513.docx
No
No
Paper Only
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Illness Prevention
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
1,571
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
1,571
0
0
0
0
1,571
Annual IC Time Burden (Hours)
131
0
0
0
0
131
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
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.