Information Collection

Facility Staff Medical Record Abstraction

IC 180565 under ICR 201302-0920-005 · OMB 0920-0740.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Att_3a_MMP abstraction_MHF_v7 1 0.doc	Instruction
Att_3b_MMP abstraction SPSF_v7 1 0.doc	Instruction
Att_3c_MMP abstraction SPVF_v7 1 0.doc	Instruction
Att_3d_MMP abstraction SPIF_v7 1 0.doc	Instruction
Att_4 minimum data set.docx Att_4 minimum data set	IC Document

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:

table that charts list of instruments
Document Type	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction	Att_3a_MMP abstraction_MHF_v7 1 0.doc	Yes	Yes	Printable Only
Instruction	Att_3b_MMP abstraction SPSF_v7 1 0.doc	Yes	Yes	Printable Only
Instruction	Att_3c_MMP abstraction SPVF_v7 1 0.doc	Yes	Yes	Printable Only
Instruction	Att_3d_MMP abstraction SPIF_v7 1 0.doc	Yes	Yes	Printable Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 7,520

Number of Respondents for Small Entity: 7,520

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	7,520	7,520
Annual IC Time Burden (Hours)	376	376
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Att_4 minimum data set	Att_4 minimum data set.docx	03/26/2012

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