Information Collection

Pharmacies questionnaire

IC 191107 under ICR 202007-0935-001 · 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⚠️ Notice: This information collection may be referencing outdated material.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 98 Pharmacies questionnaire	Form and Instruction
Attachment 98 Attachment 98 – MPC Pharmacy Provider Questionnaire Attachment 98 – MPC Pharmacy Provider Questionnaire.docx	Form and Instruction
Attachment 95 MPC Pharmacy_Fax_AF_Packet.doc Attachment 95 – MPC Pharmacy Provider Authorization Form Package, Records to be Provided via Fax Anticipated	IC Document
Attachment 96 MPC Pharmacy_Phone_AF_Packet.doc Attachment 96 – MPC Pharmacy Provider Authorization Form Package, Phone Data Collection Anticipated	IC Document
Attachment 97 MPC Pharmacy_Overflow_Patient_List.docx Attachment 97 – MPC Pharmacy Provider Overflow Patient List	IC Document
Attachment 98 MPC DME AF_Packet.docx Attachment 98 – MPC Durable Medical Equipment Provider Authorization Form Package	IC Document
Attachment 99 MPC Pharmacy Letters.docx Attachment 99 – MPC Pharmacy Provider Letters, Email Templates, and Other Documents	IC Document

IC Title:

Pharmacies questionnaire

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

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 98	Attachment 98 â MPC Pharmacy Provider Questionnaire	Attachment 98 â MPC Pharmacy 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: 6,919

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	Previously Approved
Annual Number of Responses for this IC	20,203	20,203
Annual IC Time Burden (Hours)	1,010	1,010
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachment 95 â MPC Pharmacy Provider Authorization Form Package, Records to be Provided via Fax Anticipated	Attachment 95 MPC Pharmacy_Fax_AF_Packet.doc	09/14/2015
Attachment 96 â MPC Pharmacy Provider Authorization Form Package, Phone Data Collection Anticipated	Attachment 96 MPC Pharmacy_Phone_AF_Packet.doc	09/14/2015
Attachment 97 â MPC Pharmacy Provider Overflow Patient List	Attachment 97 MPC Pharmacy_Overflow_Patient_List.docx	09/14/2015
Attachment 98 â MPC Durable Medical Equipment Provider Authorization Form Package	Attachment 98 MPC DME AF_Packet.docx	09/14/2015
Attachment 99 â MPC Pharmacy Provider Letters, Email Templates, and Other Documents	Attachment 99 MPC Pharmacy Letters.docx	09/14/2015

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