View Information Collection (IC)
View Information Collection (IC)

View Information Collection (IC)

8a_MMP 2015 Interview Questionnaire (English)
 
No Modified
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Other-WORD Yes Yes Fillable Printable
Other-WORD Yes Yes Fillable Printable
Other-WORD Yes Yes Fillable Fileable Signable

Health Public Health Monitoring

 

8,720 7,520
   
Individuals or Households
 
   100 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 8,720 0 1,200 0 0 7,520
Annual IC Time Burden (Hours) 6,540 0 6,164 0 0 376
Annual IC Cost Burden (Dollars) 142,376 0 142,376 0 0 0

Title Document Date Uploaded
4d_Model Patient Recruitment Script 03/30/2015
Att 10_Minimum Data Elements 03/30/2015
Att 9_Medical Record Abstraction Data Elements 03/30/2015
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.
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