Information Collection

Pharmacies questionnaire

IC 191107 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⚠️ Notice: This information collection may be referencing outdated material.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 #12 Pharmacies questionnaire Pharmacies questionnaire	Form and Instruction
Form #12 Pharmacies questionnaire Attachment 112 -- MPC Pharmacies Questionnaire.doc	Form and Instruction
Attachment 113 -- MPC Pharmacy Contact Guide.doc Attachment 113 -- MPC Pharmacy Contact Guide	IC Document
Attachment 114 -- MPC Pharmacy Cover Letter.doc Attachment 114 -- MPC Pharmacy Cover Letter	IC Document
Attachment 115 -- MPC Pharmacy Instructions & Customer List - FAX Version.doc Attachment 115 -- MPC Pharmacy Instructions & Customer List - FAX Version	IC Document
Attachment 116 -- MPC Pharmacy Instructions & Customer List - Phone Version.doc Attachment 116 -- MPC Pharmacy Instructions & Customer List - Phone Version	IC Document
Attachment 117 -- MPC Pharmacy FAQs BROCHURE.doc Attachment 117 -- MPC Pharmacy FAQs BROCHURE	IC Document
Attachment 118 -- MPC Pharmacy Fax Cover Sheet.doc Attachment 118 -- MPC Pharmacy Fax Cover Sheet	IC Document
Attachment 119 -- MPC Pharmacy Fax or Mail Return Form.doc Attachment 119 -- MPC Pharmacy Fax or Mail Return Form	IC Document

IC Title:

Pharmacies 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 #12				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 7,760

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	180,808	180,808
Annual IC Time Burden (Hours)	9,040	9,040
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachment 113 -- MPC Pharmacy Contact Guide		08/24/2009
Attachment 114 -- MPC Pharmacy Cover Letter		08/24/2009
Attachment 115 -- MPC Pharmacy Instructions & Customer List - FAX Version		08/24/2009
Attachment 116 -- MPC Pharmacy Instructions & Customer List - Phone Version		08/24/2009
Attachment 117 -- MPC Pharmacy FAQs BROCHURE		08/24/2009
Attachment 118 -- MPC Pharmacy Fax Cover Sheet		08/24/2009
Attachment 119 -- MPC Pharmacy Fax or Mail Return Form		08/24/2009

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

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