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Federal forms, ICRs, and supporting documents

Information Collection

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

IC 203775 under ICR 200910-0920-004 · OMB 0920-0840.

Documents and Forms
Document Name
Document Type
Form and Instruction
Other-Consent Form--English
Other-Consent Form--Spanish
Instruction
Form and Instruction
Form
Form
Form
Form
Form and Instruction
Form and Instruction
IC Document
IC Document
IC Document
IC Document
IC Document
IC Document
IC Document
IC Document
IC Document
IC Document
Information Collection (IC) Details

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 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

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 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.