Facility staff providing patient lists

Medical Monitoring Project

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0740 can be found here:

Documents and Forms

Document Name Document Type
Attachment13_Sample Sizes.doc Instruction
Attachment12_ProviSurveyLtrs.doc Provider Letters IC Document

Information Collection (IC) Details

IC Title:	Facility staff providing patient lists	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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
Instruction			Attachment13_Sample Sizes.doc		Yes	Yes	Printable Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,030	Number of Respondents for Small Entity: 1,030

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 95 %

	Approved	Previously Approved
Annual Number of Responses for this IC	1,030	1,030
Annual IC Time Burden (Hours)	515	515
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Provider Letters	Attachment12_ProviSurveyLtrs.doc	03/12/2009

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