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

Formative Research and Tool Development

OMB: 0920-0840

IC ID: 203775

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0840 can be found here:

Documents and Forms

Document Name Document Type
2012 Case-Surveillance-Based-Sampling Questionnaire for the Medical Monitoring Project (MPP) Form and Instruction
Att 7a_Model Consent Form English.doc Other-Consent Form--English
Att 7b_Model Consent Form Spanish.doc Other-Consent Form--Spanish
Att 9a_Recruitment Guidance.doc Instruction
2012 Case-Surveillance-Based-Sampling Questionnaire for Att 2_Interview.docx Form and Instruction
OMB 0920-0740 - Me Medical Record Abstraction Form Att 3a_2012_MRA_MHF.doc Form
OMB 0920-0840 Surv Surveillance Period Summary Form Att 3b_2012_MRA_SPSF1.doc Form
OMB 0920-0740 Surv Surveillance Period Visit Form Att 3c_2012_MRA_SPVF.doc Form
0920-0740 Surveill Surveillance Period Inpatient Form Att 3d_2012_MRA_SPIF.doc Form
2012 CSBS Process Documentation Form Att 5 Process Doc Form.docx Form and Instruction
Model Patient Recruitment Script Att 9b_Recruitment Guidance.docx Form and Instruction
Att 4c_MDS Lab level variables.docx Att 4c_MDS Lab level variables IC Document
Att 4a_MDS Person level variables from eHARS.docx Att 4a_MDS Person level variables from eHARS IC Document
Att 4b_MDS Person level variables constructed eHARS.docx Att 4b_MDS Person level variables constructed eHARS IC Document
Att 6a_Assurance of Confidentiality.doc Att 6a_Assurance of Confidentiality IC Document
Att 6b_DCC_Auth to operate.pdf Att 6b_DCC_Auth to operate IC Document
Att 13_Data Release Agreement.doc Att 13_Data Release Agreement IC Document
Att 14_References.doc Att 14_References IC Document
Supporting Statement A.docx Supporting Statement A IC Document
Supporting Statement B.docx Supporting Statement B IC Document
Att 1a_Sect 301 PHSA.pdf Att 1a_Sect 301 PHSA IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	2012 Case-Surveillance-Based-Sampling Questionnaire for the Medical Monitoring Project (MPP)	Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	None	2012 Case-Surveillance-Based-Sampling Questionnaire for The Medical Monitoring Project (MMP)	Att 2_Interview.docx	Yes	Yes	Fillable Fileable
Form	OMB 0920-0740 - Medical History Form	Medical Record Abstraction Form	Att 3a_2012_MRA_MHF.doc	Yes	Yes	Fillable Fileable
Form	OMB 0920-0840 Surveillance Period Summary Form	Surveillance Period Summary Form	Att 3b_2012_MRA_SPSF1.doc	Yes	Yes	Fillable Fileable
Form	OMB 0920-0740 Surveillance Period Visit Form	Surveillance Period Visit Form	Att 3c_2012_MRA_SPVF.doc	Yes	Yes	Fillable Fileable
Form	0920-0740 Surveillance Period Inpatient Form	Surveillance Period Inpatient Form	Att 3d_2012_MRA_SPIF.doc	Yes	Yes	Fillable Fileable
Form and Instruction	None	2012 CSBS Process Documentation Form	Att 5 Process Doc Form.docx	Yes	Yes	Fillable Fileable
Other-Consent Form--English			Att 7a_Model Consent Form English.doc	Yes	No	Paper Only
Other-Consent Form--Spanish			Att 7b_Model Consent Form Spanish.doc	Yes	No	Paper Only
Form and Instruction	None	Model Patient Recruitment Script	Att 9b_Recruitment Guidance.docx	Yes	No	Paper Only
Instruction			Att 9a_Recruitment Guidance.doc	Yes	Yes	Fillable Printable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,900	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 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

Documents for IC

Title	Document	Date Uploaded
Att 4c_MDS Lab level variables	Att 4c_MDS Lab level variables.docx	08/17/2012
Att 4a_MDS Person level variables from eHARS	Att 4a_MDS Person level variables from eHARS.docx	08/17/2012
Att 4b_MDS Person level variables constructed eHARS	Att 4b_MDS Person level variables constructed eHARS.docx	08/17/2012
Att 6a_Assurance of Confidentiality	Att 6a_Assurance of Confidentiality.doc	08/17/2012
Att 6b_DCC_Auth to operate	Att 6b_DCC_Auth to operate.pdf	08/17/2012
Att 13_Data Release Agreement	Att 13_Data Release Agreement.doc	08/17/2012
Att 14_References	Att 14_References.doc	08/17/2012
Supporting Statement A	Supporting Statement A.docx	08/17/2012
Supporting Statement B	Supporting Statement B.docx	08/17/2012
Att 1a_Sect 301 PHSA	Att 1a_Sect 301 PHSA.pdf	08/17/2012

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