Patients Standard Interview

Medical Monitoring Project

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

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

Information Collection (IC) Details

IC Title:	Patients Standard Interview	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Removed

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	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 %

	Program Change Due to Agency Discretion	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

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.