Information Collection

The Physician Pain Management Questionnaire

IC 246952 under ICR 202003-0920-020 · OMB 0920-1030.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
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

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:

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	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 %

table that charts list of burden
	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

table that charts IC Documents
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.