Information Collection

2021 Questionnaire

IC 180565 under ICR 202101-0920-006 · OMB 0920-0740.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0740 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
2021 Questionnaire	Form and Instruction
MMP Questionnaire 2021 - English Att 5a MMP 2021 Questionnaire English.pdf	Form and Instruction
MMP Questionnaire 2021 - English Att 5a MMP 2021 Questionnaire English.pdf	Form and Instruction
MMP Questionnaire - Spanish Att 5b MMP 2021 Questionnaire Spanish.pdf	Form and Instruction
MMP Questionnaire - Spanish Att 5b MMP 2021 Questionnaire Spanish.pdf	Form and Instruction
Att 5c MMP 2018 Questionnaire English.pdf MMP Questionnaire 2018	IC Document
Att 5c MMP 2018 Questionnaire English.pdf MMP Questionnaire 2018	IC Document

IC Title:

2021 Questionnaire

Agency IC Tracking Number:

0920-0740

Is this a Common Form? No

IC Status: Modified

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	none	MMP Questionnaire 2021 - English	Att 5a MMP 2021 Questionnaire English.pdf		Yes	Yes	Fillable Fileable
Form and Instruction	none	MMP Questionnaire - Spanish	Att 5b MMP 2021 Questionnaire Spanish.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 7,760

Number of Respondents for Small Entity: 7,520

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	7,760	0	7,760
Annual IC Time Burden (Hours)	5,173	-647	5,820
Annual IC Cost Burden (Dollars)	134,015	7,314	126,701

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
MMP Questionnaire 2018	Att 5c MMP 2018 Questionnaire English.pdf	01/19/2021

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