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

View Information Collection (IC)

2012 Case-Surveillance-Based-Sampling Questionnaire for the Medical Monitoring Project (MPP)
 
New
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction None Yes Yes Fillable Fileable
Form OMB 0920-0740 - Medical History Form Yes Yes Fillable Fileable
Form OMB 0920-0840 Surveillance Period Summary Form Yes Yes Fillable Fileable
Form OMB 0920-0740 Surveillance Period Visit Form Yes Yes Fillable Fileable
Form 0920-0740 Surveillance Period Inpatient Form Yes Yes Fillable Fileable
Form and Instruction None Yes Yes Fillable Fileable
Other-Consent Form--English Yes No Paper Only
Other-Consent Form--Spanish Yes No Paper Only
Form and Instruction None Yes No Paper Only
Instruction Yes Yes Fillable Printable

Health Immunization Management

 

1,900 0
   
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 1,900 0 0 0 0 0
Annual IC Time Burden (Hours) 655 0 0 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Att 4c_MDS Lab level variables 08/17/2012
Att 4a_MDS Person level variables from eHARS 08/17/2012
Att 4b_MDS Person level variables constructed eHARS 08/17/2012
Att 6a_Assurance of Confidentiality 08/17/2012
Att 6b_DCC_Auth to operate 08/17/2012
Att 13_Data Release Agreement 08/17/2012
Att 14_References 08/17/2012
Supporting Statement A 08/17/2012
Supporting Statement B 08/17/2012
Att 1a_Sect 301 PHSA 08/17/2012
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.
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