Information Collection

Office based providers questionnaire

IC 191103 under ICR 201808-0935-001 · 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⚠️ Notice: This information collection may be referencing outdated material.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 Attachment 83 Office based providers questionnaire	Form and Instruction
Attachment 83 Attachment 83 – MPC Office-Based Doctor Provider Questio Attachment 83 – MPC Office-Based Doctor Provider Questionnaire.docx	Form and Instruction
Attachment 80 MPC OBD_Fax_AF_Packet.doc Attachment 80 – MPC Office-Based Doctor Provider Authorization Form Package, Records to be Provided via Fax Anticipated	IC Document
Attachment 81 MPC OBD_Phone_AF_Packet.doc Attachment 81 – MPC Office-Based Doctor Provider Authorization Form Package, Phone Data Collection Anticipated	IC Document
Attachment 82 MPC OBD_Overflow_Patient_List.docx Attachment 82 – MPC Office-Based Doctor Provider Overflow Patient List	IC Document

IC Title:

Office based 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	Attachment 83	Attachment 83 â MPC Office-Based Doctor Provider Questionnaire	Attachment 83 â MPC Office-Based Doctor Provider Questionnaire.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 11,210

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	18,497	1,527	16,970
Annual IC Time Burden (Hours)	3,083	255	2,828
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachment 80 â MPC Office-Based Doctor Provider Authorization Form Package, Records to be Provided via Fax Anticipated	Attachment 80 MPC OBD_Fax_AF_Packet.doc	09/11/2015
Attachment 81 â MPC Office-Based Doctor Provider Authorization Form Package, Phone Data Collection Anticipated	Attachment 81 MPC OBD_Phone_AF_Packet.doc	09/11/2015
Attachment 82 â MPC Office-Based Doctor Provider Overflow Patient List	Attachment 82 MPC OBD_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.