Information Collection

MPC Contact Guide/Screening Call

IC 204200 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⚠️ Notice: This information collection may be referencing outdated material.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 72 MPC Contact Guide/Screening Call	Form and Instruction
Attachment 72 Attachment 72 – MPC Hospital Contact Guide Attachment 72 – MPC Hospital Contact Guide.docx	Form and Instruction
Attachment 73 Attachment 73 – MPC Office-Based Doctor Contact Guide Attachment 73 – MPC Office-Based Doctor Contact Guide.docx	Form and Instruction
Attachment 74 Attachment 74 – MPC Home Care Contact Attachment 74 – MPC Home Care Contact Guide.docx	Form and Instruction
Attachment 75 Attachment 75 – MPC Institution Contact Guide Attachment 75 – MPC Institution Contact Guide.docx	Form and Instruction
Attachment 76 Attachment 76 – MPC Pharmacy Contact Guide Attachment 76 – MPC Pharmacy Contact Guide.docx	Form and Instruction
Attachment 77 Attachment 77 – MPC Separate Billing Doctor Contact Guid Attachment 77 – MPC Separate Billing Doctor 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	Attachment 72	Attachment 72 â MPC Hospital Contact Guide	Attachment 72 â MPC Hospital Contact Guide.docx	Yes	Yes	Fillable Fileable
Form and Instruction	Attachment 73	Attachment 73 â MPC Office-Based Doctor Contact Guide	Attachment 73 â MPC Office-Based Doctor Contact Guide.docx	Yes	Yes	Fillable Fileable
Form and Instruction	Attachment 74	Attachment 74 â MPC Home Care Contact	Attachment 74 â MPC Home Care Contact Guide.docx	Yes	Yes	Fillable Fileable
Form and Instruction	Attachment 75	Attachment 75 â MPC Institution Contact Guide	Attachment 75 â MPC Institution Contact Guide.docx	Yes	Yes	Fillable Fileable
Form and Instruction	Attachment 76	Attachment 76 â MPC Pharmacy Contact Guide	Attachment 76 â MPC Pharmacy Contact Guide.docx	Yes	Yes	Fillable Fileable
Form and Instruction	Attachment 77	Attachment 77 â MPC Separate Billing Doctor Contact Guide	Attachment 77 â MPC Separate Billing Doctor 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: 36,598

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

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

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	36,598	1,376	35,222
Annual IC Time Burden (Hours)	1,220	46	1,174
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.