The Physician Pain Management Questionnaire

Developmental Studies to Improve the National Health Care Surveys

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1030 can be found here:

Documents and Forms

Document Name Document Type
The Physician Pain Management Questionnaire Form and Instruction
Physician Pain Management Questionnaire Attachment B - Survey Instrument (PPMQ).docx Form and Instruction
SS-A Physician Pain Management Questionnaire - GenIC.docx Supporting Statement Part A IC Document
SS-B Physician Pain Management Questionnaire - GenIC.docx Supporting Statement Part B IC Document
Attachment A - Final Cognitive Report -Draft (PPMQ).docx Report on Cognitive Testing of the Survey Questions IC Document
Attachment C - List of Consultants (PPMQ).docx List of Consultants IC Document
Attachment D - Recruitment Materials (PPMQ) - inclgraphics_clean.docx Recruitment Materials IC Document
Attachment E - ERB Protocol (PPMQ).docx Protocol submitted to the NCHS Ethics Review Board IC Document
0920-1030 ERB Approval.pdf ERB Approval IC Document

Information Collection (IC) Details

IC Title:	The Physician Pain Management Questionnaire	Agency IC Tracking Number:	0920-21EU

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	Physician Pain Management Questionnaire	Attachment B - Survey Instrument (PPMQ).docx		No		Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title: 09-20-0167 Health Resources Utilization Statistics	FR Citation: 49 FR 37697

Number of Respondents: 1,000	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 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,000	1,000
Annual IC Time Burden (Hours)	250	250
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Supporting Statement Part A	SS-A Physician Pain Management Questionnaire - GenIC.docx	04/22/2021
Supporting Statement Part B	SS-B Physician Pain Management Questionnaire - GenIC.docx	04/22/2021
Report on Cognitive Testing of the Survey Questions	Attachment A - Final Cognitive Report -Draft (PPMQ).docx	04/22/2021
List of Consultants	Attachment C - List of Consultants (PPMQ).docx	04/22/2021
Recruitment Materials	Attachment D - Recruitment Materials (PPMQ) - inclgraphics_clean.docx	04/22/2021
Protocol submitted to the NCHS Ethics Review Board	Attachment E - ERB Protocol (PPMQ).docx	04/22/2021
ERB Approval	0920-1030 ERB Approval.pdf	04/22/2021

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