Information Collection

MMP Short Facility Survey

IC 245511 under ICR 202012-0920-020 · OMB 0920-1340.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
MMP Short Facility Survey	Form and Instruction
Medical Monitoring Project Short Facility Survey (screen Att 7 MMP short facility survey screenshots.docx	Form and Instruction
Medical Monitoring Project Short Facility Survey (screen Att 7 MMP short facility survey screenshots.docx	Form and Instruction
MMP Short Facility Survey (Word version) Att 6 MMP short facility survey instrument final_edited.docx	Form and Instruction
MMP Short Facility Survey (Word version) Att 6 MMP short facility survey instrument final_edited.docx	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

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	Medical Monitoring Project Short Facility Survey (screenshots)	Att 7 MMP short facility survey screenshots.docx		Yes	Yes	Fillable Fileable
Form and Instruction	n/a	MMP Short Facility Survey (Word version)	Att 6 MMP short facility survey instrument final_edited.docx		No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 225

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 90 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	225	225
Annual IC Time Burden (Hours)	19	19
Annual IC Cost Burden (Dollars)	659	659

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.