Survey of Clinicians and Office Staff

Patient-Reported Health Information Technology and Workflow

Documents and Forms

Document Name Document Type
Form Form #6 Survey of Clinicians and Office Staff Form and Instruction
Form #6 Clinician and Office Staff Survey Attachment I -- Clinician and Office Staff Survey.docx Form and Instruction
Attachment H -- Clinician and Office Staff Survey Invitation.docx Attachment H -- Clinician and Office Staff Survey Invitation IC Document
Attachment H -- Clinician and Office Staff Survey Invitation.docx Attachment H -- Clinician and Office Staff Survey Invitation IC Document

Information Collection (IC) Details

IC Title:	Survey of Clinicians and Office Staff	Agency IC Tracking Number:

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	Form #6	Clinician and Office Staff Survey	Attachment I -- Clinician and Office Staff Survey.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 138	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	138	138
Annual IC Time Burden (Hours)	35	35
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Attachment H -- Clinician and Office Staff Survey Invitation	Attachment H -- Clinician and Office Staff Survey Invitation.docx	05/07/2013
Attachment H -- Clinician and Office Staff Survey Invitation	Attachment H -- Clinician and Office Staff Survey Invitation.docx	05/07/2013

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