Health Care Providers and Suppliers

OMHA Annual Appellant Climate Survey

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0990-0330 can be found here:

Documents and Forms

Document Name Document Type
Appendix B1 Appellant Climate Survey-Telephone (English).docx Other-survey
Appendix B2 Appellant Climate Survey-Telephone (Spanish).docx Other-form
Appendix B3 Appellant Climate Survey-Mail (English).docx Other-Survey
Appendix B4 Appellant Climate Survey-Mail (Spanish).docx Other-survey
Appendix B5 Appellant Climate Survey-Web (English).docx Other-survey
Appendix B6 Appellant Climate Survey-Web (Spanish).docx Other-survey

Information Collection (IC) Details

IC Title:	Health Care Providers and Suppliers	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-survey	Appendix B1 Appellant Climate Survey-Telephone (English).docx	Yes	Yes	Fillable Fileable
Other-form	Appendix B2 Appellant Climate Survey-Telephone (Spanish).docx	No		Paper Only
Other-Survey	Appendix B3 Appellant Climate Survey-Mail (English).docx	No		Paper Only
Other-survey	Appendix B4 Appellant Climate Survey-Mail (Spanish).docx	No		Paper Only
Other-survey	Appendix B5 Appellant Climate Survey-Web (English).docx	Yes	Yes	Fillable Fileable
Other-survey	Appendix B6 Appellant Climate Survey-Web (Spanish).docx	Yes	Yes	Fillable Fileable

Line of Business: General Government

Subfunction: Executive Functions

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 200	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	200	-40	240
Annual IC Time Burden (Hours)	50	6	44
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.