Information Collection

Provider Assessment

IC 216768 under ICR 201803-2900-005 · OMB 2900-0843.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2900-0843 can be found here:

Documents and Forms

Document Name Document Type
Form 10-10162 Provider Assessment Form and Instruction
10-10162 Provider Assessment proposed_2019 CHALENG Provider Survey_Word.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Provider Assessment	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	10-10162	Provider Assessment	proposed_2019 CHALENG Provider Survey_Word.docx		No		Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 4,700	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	4,700	-3,300	8,000
Annual IC Time Burden (Hours)	705	-362	1,067
Annual IC Cost Burden (Dollars)	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.