Information Collection

Home care for non health care providers questionnaire

IC 191102 under ICR 201509-0935-001 · OMB 0935-0118.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0935-0118 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Form #1 Home care for non health care providers questionnaire	Form and Instruction
Form #1 Home care for non health care providers questionnaire Attachment 78 MPC Home Care NonHealth Event Form.docx	Form and Instruction
Attachment 75 MPC HomeHealth_Phone_AF_Packet.doc Attachment 75 – MPC Home Care Provider Authorization Form Package, Phone Data Collection Anticipated	IC Document
Attachment 76 MPC HomeHealth_Fax_AF_Packet.doc Attachment 76 – MPC Home Care Provider Authorization Form Package, Records to be Provided via Fax Anticipated	IC Document
Attachment 77 MPC HomeHealth_Overflow_Patient_List.docx Attachment 77 – MPC Home Care Provider Overflow Patient List	IC Document

IC Title:

Home care for non health care providers questionnaire

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 and Instruction	Form #1	Home care for non health care providers questionnaire	Attachment 78 MPC Home Care NonHealth Event Form.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 25

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	25	-206	231
Annual IC Time Burden (Hours)	5	-14	19
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachment 75 â MPC Home Care Provider Authorization Form Package, Phone Data Collection Anticipated	Attachment 75 MPC HomeHealth_Phone_AF_Packet.doc	09/11/2015
Attachment 76 â MPC Home Care Provider Authorization Form Package, Records to be Provided via Fax Anticipated	Attachment 76 MPC HomeHealth_Fax_AF_Packet.doc	09/11/2015
Attachment 77 â MPC Home Care Provider Overflow Patient List	Attachment 77 MPC HomeHealth_Overflow_Patient_List.docx	09/11/2015

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