Information Collection

Testing Solutions for Sampling Challenges for MMP

IC 207572 under ICR 201301-0920-010 · OMB 0920-0840.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0840 can be found here:

Documents and Forms

Document Name Document Type
Testing Solutions for Sampling Challenges for MMP Form
2a - Interview questionnaire - English MMP GenIC_Testing Sampling_Att 2a_MMP Formative Research Interview_English.docx Form
2b - interview questionnaire - Spanish MMP GenIC_Testing Sampling_Att 2b_MMP Formative Research Interview_Spanish.docx Form
MMP GenIC_Testing Sampling_Supporting Statement A.docx Supporting Statement A IC Document
MMP GenIC_Testing Sampling_Supporting Statement B.docx Supporting Statement B IC Document
MMP GenIC_Testing Sampling_Att 1_Research Sect 301 PHSA.pdf 1 - Authorizing Legislation IC Document
MMP GenIC_Testing Sampling_Att 3a_MMP_2013_MRA_MHF_v7 1 0.doc 3a - MMP Medical Record Abstraction form IC Document
MMP GenIC_Testing Sampling_Att 3b_MMP_2013_MRA_SPSF_v7 1 0.doc 3b - MMP Surveillance Summary Form IC Document
MMP GenIC_Testing Sampling_Att 3c_MMP_2013_MRA_SPVF_v7 1 0.doc 3c - MMP Surveillance Visit Form IC Document
MMP GenIC_Testing Sampling_Att 3d_MMP_2013_MRA_SPIF_v7 1 0.doc 3d - MMP Surveillance Inpatient Form IC Document
MMP GenIC_Testing Sampling_Att 4a_MMP_MDS Person level variables_eHARS.docx 4a - MMP variables IC Document
MMP GenIC_Testing Sampling_Att 4b_MMP_MDS Person level variables based on eHARS.docx 4b - MMP variables IC Document
MMP GenIC_Testing Sampling_Att 4c_MMP_MDS Lab level variables.docx 4c - MMP variables IC Document
MMP GenIC_Testing Sampling_Att 5a MMP_Research Process Doc Form.docx 5a - Process documentation form IC Document
MMP GenIC_Testing Sampling_Att 5b MMP_Contact Attempt Tracking Database.docx 5b - Contact attempt tracking IC Document
MMP GenIC_Testing Sampling_Att 6a_MMP_Assurance of Conf.doc 6a - Assurance of Confidentiality IC Document
MMP GenIC_Testing Sampling_Att 6b_MMP_DCC_Auth to operate.pdf 6b - Authorization to Operate IC Document
MMP GenIC_Testing Sampling_Att 7_MMP_Recruitment Guidance_First Contact.docx 7 - Recruitment script IC Document
MMP GenIC_Testing Sampling_Att 8_MMP_Data Release Agreement.doc 8 - Data release agreement IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Testing Solutions for Sampling Challenges for MMP	Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	none	2a - Interview questionnaire - English	MMP GenIC_Testing Sampling_Att 2a_MMP Formative Research Interview_English.docx		Yes	Yes	Fillable Fileable
Form	none	2b - interview questionnaire - Spanish	MMP GenIC_Testing Sampling_Att 2b_MMP Formative Research Interview_Spanish.docx		Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 2,850	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to New Statute	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA	Previously Approved
Annual Number of Responses for this IC	2,850	0	0	0	0	0
Annual IC Time Burden (Hours)	983	0	0	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
Supporting Statement A	MMP GenIC_Testing Sampling_Supporting Statement A.docx	06/24/2013
Supporting Statement B	MMP GenIC_Testing Sampling_Supporting Statement B.docx	06/24/2013
1 - Authorizing Legislation	MMP GenIC_Testing Sampling_Att 1_Research Sect 301 PHSA.pdf	06/24/2013
3a - MMP Medical Record Abstraction form	MMP GenIC_Testing Sampling_Att 3a_MMP_2013_MRA_MHF_v7 1 0.doc	06/24/2013
3b - MMP Surveillance Summary Form	MMP GenIC_Testing Sampling_Att 3b_MMP_2013_MRA_SPSF_v7 1 0.doc	06/24/2013
3c - MMP Surveillance Visit Form	MMP GenIC_Testing Sampling_Att 3c_MMP_2013_MRA_SPVF_v7 1 0.doc	06/24/2013
3d - MMP Surveillance Inpatient Form	MMP GenIC_Testing Sampling_Att 3d_MMP_2013_MRA_SPIF_v7 1 0.doc	06/24/2013
4a - MMP variables	MMP GenIC_Testing Sampling_Att 4a_MMP_MDS Person level variables_eHARS.docx	06/24/2013
4b - MMP variables	MMP GenIC_Testing Sampling_Att 4b_MMP_MDS Person level variables based on eHARS.docx	06/24/2013
4c - MMP variables	MMP GenIC_Testing Sampling_Att 4c_MMP_MDS Lab level variables.docx	06/24/2013
5a - Process documentation form	MMP GenIC_Testing Sampling_Att 5a MMP_Research Process Doc Form.docx	06/24/2013
5b - Contact attempt tracking	MMP GenIC_Testing Sampling_Att 5b MMP_Contact Attempt Tracking Database.docx	06/24/2013
6a - Assurance of Confidentiality	MMP GenIC_Testing Sampling_Att 6a_MMP_Assurance of Conf.doc	06/24/2013
6b - Authorization to Operate	MMP GenIC_Testing Sampling_Att 6b_MMP_DCC_Auth to operate.pdf	06/24/2013
7 - Recruitment script	MMP GenIC_Testing Sampling_Att 7_MMP_Recruitment Guidance_First Contact.docx	06/24/2013
8 - Data release agreement	MMP GenIC_Testing Sampling_Att 8_MMP_Data Release Agreement.doc	06/24/2013

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