Information Collection

8a_MMP 2018 Questionnaire (English)

IC 180565 under ICR 201805-0920-003 · 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⚠️ Notice: This information collection may be referencing outdated material.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
Form 0920-0740 8a_MMP 2018 Questionnaire (English)	Form
0920-0740 Medical Monitoring Project 2018 Questionnaire v.14.1.0 Att 8a_2015 Questionnaire English.pdf	Form
0920-0222 MMP 2018 Cuestionario v.14.0.7 Att 8b_MMP Questionnaire Spanish.pdf	Form
0920-0222 MMP 2015-2017 Questionnaire v 11.2.3 Att 8c_MMP 2015 Questionnaire English.pdf	Form
Att 11d_MMP Recruitment Text E-mail.docx 11d_Model Patient Recruitment Script	IC Document
Att 4_Minimum Dataset Elements.docx Att 4_ Minimum Data Element	IC Document
Att 13_MMP MRA Data Structure.docx Att 13_Medical Record Abstraction Data Elements	IC Document

IC Title:

8a_MMP 2018 Questionnaire (English)

Agency IC Tracking Number:

0920-0740

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	0920-0740	Medical Monitoring Project 2018 Questionnaire v.14.1.0	Att 8a_2015 Questionnaire English.pdf	Yes	Yes	Fillable Printable
Form	0920-0222	MMP 2018 Cuestionario v.14.0.7	Att 8b_MMP Questionnaire Spanish.pdf	Yes	Yes	Fillable Printable
Form	0920-0222	MMP 2015-2017 Questionnaire v 11.2.3	Att 8c_MMP 2015 Questionnaire English.pdf	No		Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 7,760

Number of Respondents for Small Entity: 7,520

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	7,760	-960	8,720
Annual IC Time Burden (Hours)	5,820	-720	6,540
Annual IC Cost Burden (Dollars)	126,701	-15,675	142,376

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
11d_Model Patient Recruitment Script	Att 11d_MMP Recruitment Text E-mail.docx	05/17/2018
Att 4_ Minimum Data Element	Att 4_Minimum Dataset Elements.docx	05/17/2018
Att 13_Medical Record Abstraction Data Elements	Att 13_MMP MRA Data Structure.docx	05/17/2018

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