Information Collection

Authorization form for the MEPS-MPC Provider Survey

IC 204197 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⚠️ Notice: This information collection may be referencing outdated material.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

Document Name Document Type
Form Form #1 Authorization form for the MEPS-MPC Provider Survey Form and Instruction
Form #1 Authorization Form for the MEPS-MPC - Provider 22-HC Authorization Form for the MEPS-MPC - Provider.doc Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Authorization form for the MEPS-MPC Provider Survey	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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 and Instruction	Form #1	Authorization Form for the MEPS-MPC - Provider	22-HC Authorization Form for the MEPS-MPC - Provider.doc		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 14,489	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	78,241	2,898	75,343
Annual IC Time Burden (Hours)	3,912	145	3,767
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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