Information Collection

Separately billing doctors questionnaire

IC 191104 under ICR 201209-0935-001 · 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⚠️ Notice: This information collection may be referencing outdated material.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 #1 Separately billing doctors questionnaire	Form and Instruction
Form #1 Separately billing doctors questionnaire Attachment 36 -- MPC SBD Questionnaire.doc	Form and Instruction
Attachment 38 -- MPC SBD Respondent Materials - Fax Version.doc Attachment 38 -- MPC SBD Respondent Materials - Fax Version	IC Document
Attachment 39 -- MPC SBD Respondent Materials - Phone Version.doc Attachment 39 -- MPC SBD Respondent Materials - Phone Version	IC Document

IC Title:

Separately billing doctors questionnaire

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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 #1	Separately billing doctors questionnaire	Attachment 36 -- MPC SBD Questionnaire.doc		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 10,800

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	Previously Approved
Annual Number of Responses for this IC	21,600	-3,300	24,900
Annual IC Time Burden (Hours)	1,080	-165	1,245
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachment 38 -- MPC SBD Respondent Materials - Fax Version	Attachment 38 -- MPC SBD Respondent Materials - Fax Version.doc	09/24/2012
Attachment 39 -- MPC SBD Respondent Materials - Phone Version	Attachment 39 -- MPC SBD Respondent Materials - Phone Version.doc	09/24/2012

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