MTM Partner Site-Level Interview

National Evaluation of the DP18-1815 Cooperative Agreement Program: Category B, Cardiovascular Disease Prevention and Management

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1311 can be found here:

Documents and Forms

Document Name Document Type
MTM Partner Site-Level Interview Form and Instruction
MTM Partner Site Interview Guide Att 4h. MTM Partner Site Interview Guide B4.docx Form and Instruction
MTM Partner Site Interview Guide for Pharmacists Att 4i. MTM Partner Site Interview Guide B4.docx Form and Instruction

Information Collection (IC) Details

IC Title:	MTM Partner Site-Level Interview	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

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	n/a	MTM Partner Site Interview Guide	Att 4h. MTM Partner Site Interview Guide B4.docx		No		Paper Only
Form and Instruction	n/a	MTM Partner Site Interview Guide for Pharmacists	Att 4i. MTM Partner Site Interview Guide B4.docx		No		Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 7	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 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	7	7
Annual IC Time Burden (Hours)	7	7
Annual IC Cost Burden (Dollars)	560	560

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.