Information Collection

MPC Contact Guide/Screening Call

IC 204200 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⚠️ Notice: This information collection may be referencing outdated material.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 MPC Contact Guide/Screening Call	Form and Instruction
Form #1 Home Health Contact Guide for Organizations Attachment 68 MPC Hospital Contact Guide.docx	Form and Instruction
Form #2 Office Based Contact Guide Attachment 69 MPC Office Based Doctors Contact Guide.docx	Form and Instruction
Form #3 SBD Contact Guide Attachment 73 MPC Separately Billing Doctors Contact Guide.docx	Form and Instruction
Form #4 Hospital Contact Guide Attachment 70 MPC Home Care Contact Guide.docx	Form and Instruction
Form #5 Institution Contact Guide Attachment 71 MPC Institution Contact Guide.docx	Form and Instruction
Form #6 Pharmacy Contact Guide Attachment 72 MPC Pharmacy Contact Guide.docx	Form and Instruction

IC Title:

MPC Contact Guide/Screening Call

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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	Form #1	Home Health Contact Guide for Organizations	Attachment 68 MPC Hospital Contact Guide.docx	Yes	Yes	Fillable Fileable
Form and Instruction	Form #2	Office Based Contact Guide	Attachment 69 MPC Office Based Doctors Contact Guide.docx	Yes	Yes	Fillable Fileable
Form and Instruction	Form #3	SBD Contact Guide	Attachment 73 MPC Separately Billing Doctors Contact Guide.docx	Yes	Yes	Fillable Fileable
Form and Instruction	Form #4	Hospital Contact Guide	Attachment 70 MPC Home Care Contact Guide.docx	Yes	Yes	Fillable Fileable
Form and Instruction	Form #5	Institution Contact Guide	Attachment 71 MPC Institution Contact Guide.docx	Yes	Yes	Fillable Fileable
Form and Instruction	Form #6	Pharmacy Contact Guide	Attachment 72 MPC Pharmacy Contact Guide.docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 35,222

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	35,222	1,222	34,000
Annual IC Time Burden (Hours)	1,174	-526	1,700
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
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.