Information Collection

Institutions (non-hospital) questionnaire

IC 191106 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⚠️ Notice: This information collection may be referencing outdated material.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 #11 Institutions (non-hospital) questionnaire	Form and Instruction
Form #11 Institutions (non-hospital) questionnaire Attachment 109 -- MPC Institutions (non-hospital) Questionnaire.doc	Form and Instruction
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:

Institutions (non-hospital) 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 #11	Institutions (non-hospital) questionnaire	Attachment 109 -- MPC Institutions (non-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: 72

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	108	108
Annual IC Time Burden (Hours)	9	9
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
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.