Information Collection

Prescription Monitoring Program Questionnaire

IC 12344 under ICR 200902-1117-002 · OMB 1117-0037.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form OMB Number 1117-00 Prescription Monitoring Program Questionnaire	Form and Instruction
OMB Number 1117-00 Prescription Monitoring Program Questionnaire questionnaire prescription monitoring program- 040109.doc	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	OMB Number 1117-0037	Prescription Monitoring Program Questionnaire	questionnaire prescription monitoring program- 040109.doc		Yes	Yes	Fillable Fileable Signable

Line of Business: Law Enforcement

Subfunction: Substance Control

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 51

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 50 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	51	51
Annual IC Time Burden (Hours)	255	255
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.