Information Collection

Medical Office Information Form

IC 201168 under ICR 201202-0935-005 · OMB 0935-0196.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0935-0196 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Form #3 Medical Office Information Form	Form
Form #3 Medical Office Information Form Attachment D Medical Office Information Form revised 5-15-2012.docx	Form

IC Title:

Medical Office Information Form

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	Form #3	Medical Office Information Form	Attachment D Medical Office Information Form revised 5-15-2012.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 150

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	1,500	1,500
Annual IC Time Burden (Hours)	125	125
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.