Medical Monitoring Project

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Patient Short interview	Form	Modified	Available
Patients Standard Interview	Form	Modified	Available
MMP 2014 Summary of Changes to Questionnaire.docx	Supplementary Document	Uploaded 2013-11-21	Available
MMP 0920-0740_OMB_Justification 2013 11 21 clean.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2013-11-21	Available
Att_4 minimum data set.docx	Supplementary Document	Uploaded 2012-03-26	Available
MMP 2013 Interview v.9.5.0_Redlined.docx	Supplementary Document	Uploaded 2013-01-30	Available
Attachment11_Model Scripts.doc	Supplementary Document	Uploaded 2009-03-12	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
180569	Approaching Sampled Patients for Enrollment	Instruction	Modified
180568	Providing Patient Lists for Medical Monitoring Project Patient Sampling	Instruction	Modified
180566	Facility staff Providing Estimated Patient Loads	Instruction	Modified
180565	Facility Staff Medical Record Abstraction	Instruction	Modified
178498	Patient Short interview	Form	Modified
178497	Patients Standard Interview	Form	Modified

ICR Details

OMB Control No: 0920-0740	ICR Reference No: 201311-0920-014
Status: Historical Active	Previous ICR Reference No: 201302-0920-005
Agency/Subagency: HHS/CDC	Agency Tracking No: 20996
Title: Medical Monitoring Project
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 11/25/2013
	Date Received in OIRA: 11/21/2013
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	05/31/2015	05/31/2015	05/31/2015
Responses	20,126	0	20,126
Time Burden (Hours)	8,537	0	8,537
Cost Burden (Dollars)	0	0	0

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Abstract: This request is to make minor changes to the questionnaire with no change in burden or respondents.

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Authorizing Statute(s): PL: Pub.L. 111 - 241 301 Name of Law: Title III - General Powers and Duties of Public Health Service
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 6

table that charts list of burden

IC Title	Form No.	Form Name
Facility staff Providing Estimated Patient Loads
Patients Standard Interview	None	2014 Standard Questionnaire for Medical Monitoring Project (MMP)
Patient Short interview	none	Standard Interview
Facility Staff Medical Record Abstraction
Providing Patient Lists for Medical Monitoring Project Patient Sampling
Approaching Sampled Patients for Enrollment

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ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	20,126	20,126	0	0	0	0
Annual Time Burden (Hours)	8,537	8,537	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $14,700,128

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 11/21/2013

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