Health Care Provider Interviews

Evaluation of the Children's Health Insurance Program Reauthorization Act of 2009 (CHIPRA) Quality Demonstration Grant Program

Documents and Forms

Document Name Document Type
Form 8 Health Care Provider Interviews Form and Instruction
8 2012 Health Care Organization Staff Interview Guides Attachment I - 2012 Health Care Provider Interview Guide.docx Form and Instruction
9 2014 Health Care Organization Staff Interview Guide Attachment J -2014 Health Care Organization Staff Interview Guide.docx Form and Instruction
Attachment C- Interview Request and Confirmation Emails.docx Attachment C- Interview Request and Confirmation Emails IC Document

Information Collection (IC) Details

IC Title:	Health Care Provider Interviews	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	8	2012 Health Care Organization Staff Interview Guides	Attachment I - 2012 Health Care Provider Interview Guide.docx		Yes	Yes	Paper Only
Form and Instruction	9	2014 Health Care Organization Staff Interview Guide	Attachment J -2014 Health Care Organization Staff Interview Guide.docx		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 216	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	Previously Approved
Annual Number of Responses for this IC	432	216	216
Annual IC Time Burden (Hours)	324	162	162
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Attachment C- Interview Request and Confirmation Emails	Attachment C- Interview Request and Confirmation Emails.docx	02/18/2014

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