Information Collection

Hospitals questionnaire

IC 191105 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⚠️ Notice: This information collection may be referencing outdated material.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 #10 Hospitals questionnaire	Form and Instruction
Form #10 Hospitals questionnaire Attachment 99 -- MPC Hospital Questionnaire.doc	Form and Instruction
Attachment 100 -- MPC Hospital Contact Guide.doc Attachment 100 -- MPC Hospital Contact Guide	IC Document
Attachment 101 -- MPC Hospital Cover Letter.doc Attachment 101 -- MPC Hospital Cover Letter	IC Document
Attachment 102 -- MPC Hospital FAQs BROCHURE.DOC Attachment 102 -- MPC Hospital FAQs BROCHURE	IC Document
Attachment 103 -- MPC Hospital Fax Cover Sheet.doc Attachment 103 -- MPC Hospital Fax Cover Sheet	IC Document
Attachment 104 -- MPC Hospital Fax or Mail Return Form.doc Attachment 104 -- MPC Hospital Fax or Mail Return Form	IC Document
Attachment 105 -- MPC Hospital Instructions & Patient Accounts Check List - FAX Version.doc Attachment 105 -- MPC Hospital Instructions & Patient Accounts Check List - FAX Version	IC Document
Attachment 106 -- MPC Hospital Instructions & Patient Accounts Check List - Phone Version.doc Attachment 106 -- MPC Hospital Instructions & Patient Accounts Check List - Phone Version	IC Document
Attachment 107 -- MPC Hospital Instructions & Patient Records Check List - Fax Version.doc Attachment 107 -- MPC Hospital Instructions & Patient Records Check List - Fax Version	IC Document
Attachment 108 -- MPC Hospital Instructions & Patient Records Check List - Phone Version.doc Attachment 108 -- MPC Hospital Instructions & Patient Records Check List - Phone Version	IC Document

IC Title:

Hospitals 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 #10	Hospitals questionnaire	Attachment 99 -- MPC Hospital 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: 5,402

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	35,113	35,113
Annual IC Time Burden (Hours)	2,926	2,926
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachment 100 -- MPC Hospital Contact Guide	Attachment 100 -- MPC Hospital Contact Guide.doc	08/24/2009
Attachment 101 -- MPC Hospital Cover Letter	Attachment 101 -- MPC Hospital Cover Letter.doc	08/24/2009
Attachment 102 -- MPC Hospital FAQs BROCHURE	Attachment 102 -- MPC Hospital FAQs BROCHURE.DOC	08/24/2009
Attachment 103 -- MPC Hospital Fax Cover Sheet	Attachment 103 -- MPC Hospital Fax Cover Sheet.doc	08/24/2009
Attachment 104 -- MPC Hospital Fax or Mail Return Form	Attachment 104 -- MPC Hospital Fax or Mail Return Form.doc	08/24/2009
Attachment 105 -- MPC Hospital Instructions & Patient Accounts Check List - FAX Version	Attachment 105 -- MPC Hospital Instructions & Patient Accounts Check List - FAX Version.doc	08/24/2009
Attachment 106 -- MPC Hospital Instructions & Patient Accounts Check List - Phone Version	Attachment 106 -- MPC Hospital Instructions & Patient Accounts Check List - Phone Version.doc	08/24/2009
Attachment 107 -- MPC Hospital Instructions & Patient Records Check List - Fax Version	Attachment 107 -- MPC Hospital Instructions & Patient Records Check List - Fax Version.doc	08/24/2009
Attachment 108 -- MPC Hospital Instructions & Patient Records Check List - Phone Version	Attachment 108 -- MPC Hospital Instructions & Patient Records Check List - Phone Version.doc	08/24/2009

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