Facility Staff Medical Record Abstraction

Medical Monitoring Project

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0740 can be found here:

Documents and Forms

Document Name Document Type
Attachment6_aMHF.doc Instruction
Attachment6c_SPSummary Form.doc Instruction
Attachment6b_SPIF.doc Instruction
Attachment6d_SPVisit Form.doc Instruction
atachment4c_MinimalData.doc Instruction

Information Collection (IC) Details

IC Title:	Facility Staff Medical Record Abstraction	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction	Attachment6_aMHF.doc	Yes	No	Printable Only
Instruction	Attachment6c_SPSummary Form.doc	Yes	Yes	Printable Only
Instruction	Attachment6b_SPIF.doc	Yes	Yes	Printable Only
Instruction	Attachment6d_SPVisit Form.doc	Yes	Yes	Printable Only
Instruction	atachment4c_MinimalData.doc	Yes	Yes	Printable Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 7,488	Number of Respondents for Small Entity: 7,488

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 95 %

	Approved	Previously Approved
Annual Number of Responses for this IC	7,488	7,488
Annual IC Time Burden (Hours)	374	374
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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