Information Collection

Patients Standard Interview

IC 178497 under ICR 201311-0920-014 · 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⚠️ Notice: This information collection may be referencing outdated material.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
Patients Standard Interview	Form
2014 Standard Questionnaire for Medical Monitoring Proje MMP 2014 interview v10.0.2 clean.docx	Form
Attachment11_Model Scripts.doc Provider/Patient Model Scripts	IC Document
MMP 2013 Interview v.9.5.0_Redlined.docx Redlined version of Standard Interview	IC Document

IC Title:

Patients Standard Interview

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	None	2014 Standard Questionnaire for Medical Monitoring Project (MMP)	MMP 2014 interview v10.0.2 clean.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 7,219

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	7,219	7,219
Annual IC Time Burden (Hours)	5,414	5,414
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Provider/Patient Model Scripts	Attachment11_Model Scripts.doc	03/12/2009
Redlined version of Standard Interview	MMP 2013 Interview v.9.5.0_Redlined.docx	01/30/2013

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