Information Collection

Office based providers questionnaire

IC 191103 under ICR 200910-0935-001 · OMB 0935-0118.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0935-0118 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Form #8 Office based providers questionnaire	Form and Instruction
Form #8 Office based providers questionnaire Attachment 84 -- MPC Office Based Providers Questionnaire.doc	Form and Instruction
Attachment 85 -- MPC Office Based Cover Letter.doc Attachment 85 -- MPC Office Based Cover Letter	IC Document
Attachment 86 -- MPC Office Based FAQs Brochure.doc Attachment 86 -- MPC Office Based FAQs Brochure	IC Document
Attachment 87 -- MPC Office Based Fax Cover Sheet.doc Attachment 87 -- MPC Office Based Fax Cover Sheet	IC Document
Attachment 88 -- MPC Office Based Fax or Mail Return Form.doc Attachment 88 -- MPC Office Based Fax or Mail Return Form	IC Document
Attachment 89 -- MPC Office Based Instructions & Patient List - FAX Version.doc Attachment 89 -- MPC Office Based Instructions & Patient List - FAX Version	IC Document
Attachment 90 -- MPC Office Based Instructions & Patient List - Phone Version.doc Attachment 90 -- MPC Office Based Instructions & Patient List - Phone Version	IC Document
Attachment 91 -- MPC Office Based Contact Guide.doc Attachment 91 -- MPC Office Based Contact Guide	IC Document

IC Title:

Office based providers questionnaire

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

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	Form #8	Office based providers questionnaire	Attachment 84 -- MPC Office Based Providers Questionnaire.doc		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 13,665

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 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	79,257	79,257
Annual IC Time Burden (Hours)	6,605	6,605
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachment 85 -- MPC Office Based Cover Letter	Attachment 85 -- MPC Office Based Cover Letter.doc	08/24/2009
Attachment 86 -- MPC Office Based FAQs Brochure	Attachment 86 -- MPC Office Based FAQs Brochure.doc	08/24/2009
Attachment 87 -- MPC Office Based Fax Cover Sheet	Attachment 87 -- MPC Office Based Fax Cover Sheet.doc	08/24/2009
Attachment 88 -- MPC Office Based Fax or Mail Return Form	Attachment 88 -- MPC Office Based Fax or Mail Return Form.doc	08/24/2009
Attachment 89 -- MPC Office Based Instructions & Patient List - FAX Version	Attachment 89 -- MPC Office Based Instructions & Patient List - FAX Version.doc	08/24/2009
Attachment 90 -- MPC Office Based Instructions & Patient List - Phone Version	Attachment 90 -- MPC Office Based Instructions & Patient List - Phone Version.doc	08/24/2009
Attachment 91 -- MPC Office Based Contact Guide	Attachment 91 -- MPC Office Based Contact Guide.doc	08/24/2009

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