Health Professional Impact Survey

Pediatric Mental Health Care Access Program National Impact Study

Documents and Forms

Document Name Document Type
Form 1 Health Professional Impact Survey Form and Instruction
1 Health Professional Impact Survey Attachment B1 - HP Impact Survey_Final.docx Form and Instruction
1 Health Professional Impact Survey Attachment B1 - HP Impact Survey_Final.docx Form and Instruction
Attachment B4 - HP Impact Survey Consent_Final.docx Attachment B4 - HP Impact Survey Consent_Final IC Document
Attachment B4 - HP Impact Survey Consent_Final.docx Attachment B4 - HP Impact Survey Consent_Final IC Document

Information Collection (IC) Details

IC Title:	Health Professional Impact Survey	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	1	Health Professional Impact Survey	Attachment B1 - HP Impact Survey_Final.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 21,070	Number of Respondents for Small Entity: 21,070

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

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	42,140	42,140
Annual IC Time Burden (Hours)	7,164	7,164
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Attachment B4 - HP Impact Survey Consent_Final	Attachment B4 - HP Impact Survey Consent_Final.docx	04/30/2024

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