Information Collection

Institutions (non-hospital) questionnaire

IC 191106 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⚠️ Notice: This information collection may be referencing outdated material.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 Institutions (non-hospital) questionnaire	Form and Instruction
Form #1 Institutions (non-hospital) questionnaire Attachment 46 -- MPC Institutions (non-hospital) Questionnaire.doc	Form and Instruction
Attachment 42 -- MPC Hospital Respondent Materials - Patient Accounts - FAX Version.doc Attachment 42 -- MPC Hospital Respondent Materials - Patient Accounts - FAX Version	IC Document
Attachment 43 -- MPC Hospital Respondent Materials - Patient Accounts - Phone Version.doc Attachment 43 -- MPC Hospital Respondent Materials - Patient Accounts - Phone Version	IC Document
Attachment 44 -- MPC Hospital Respondent Materials - Patient Records - Fax Version.doc Attachment 44 -- MPC Hospital Respondent Materials - Patient Records - Fax Version	IC Document
Attachment 45 -- MPC Hospital Respondent Materials - Patient Records - Phone Version.doc Attachment 45 -- MPC Hospital Respondent Materials - Patient Records - Phone Version	IC Document

IC Title:

Institutions (non-hospital) 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	Institutions (non-hospital) questionnaire	Attachment 46 -- MPC Institutions (non-hospital) Questionnaire.doc		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 100

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	150	42	108
Annual IC Time Burden (Hours)	13	4	9
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachment 42 -- MPC Hospital Respondent Materials - Patient Accounts - FAX Version	Attachment 42 -- MPC Hospital Respondent Materials - Patient Accounts - FAX Version.doc	09/24/2012
Attachment 43 -- MPC Hospital Respondent Materials - Patient Accounts - Phone Version	Attachment 43 -- MPC Hospital Respondent Materials - Patient Accounts - Phone Version.doc	09/24/2012
Attachment 44 -- MPC Hospital Respondent Materials - Patient Records - Fax Version	Attachment 44 -- MPC Hospital Respondent Materials - Patient Records - Fax Version.doc	09/24/2012
Attachment 45 -- MPC Hospital Respondent Materials - Patient Records - Phone Version	Attachment 45 -- MPC Hospital Respondent Materials - Patient Records - Phone Version.doc	09/24/2012

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