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Agenda
Reg Review
ICR
View Information Collection (IC)
View Information Collection (IC)
IC Title:
Office based providers questionnaire
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
Unchanged
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
Attachment 83
Attachment 83 – MPC Office-Based Doctor Provider Questionnaire
Attachment 83 – MPC Office-Based Doctor Provider Questionnaire.docx
Yes
Yes
Fillable Fileable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Immunization Management
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
11,210
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 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
18,497
0
0
0
0
18,497
Annual IC Time Burden (Hours)
3,083
0
0
0
0
3,083
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
Attachment 80 – MPC Office-Based Doctor Provider Authorization Form Package, Records to be Provided via Fax Anticipated
Attachment 80 MPC OBD_Fax_AF_Packet.doc
09/11/2015
Attachment 81 – MPC Office-Based Doctor Provider Authorization Form Package, Phone Data Collection Anticipated
Attachment 81 MPC OBD_Phone_AF_Packet.doc
09/11/2015
Attachment 82 – MPC Office-Based Doctor Provider Overflow Patient List
Attachment 82 MPC OBD_Overflow_Patient_List.docx
09/11/2015
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.