Information Collection

Monthly Outcome Survey (MOS)

IC 245272 under ICR 202101-0990-001 · OMB 0990-0475.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0990-0475 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Attachment D Monthly Outcome Survey (MOS)	Form and Instruction
Attachment D Attachment D: COVID-19 Monthly Outcome Survey – Question Part A_Attachment D_COVID-19 Monthly Outcome Survey_Questionnaire.docx	Form and Instruction
Attachment E Attachment E: COVID-19 Monthly Outcome Survey – Ipsos Om Part A_Attachment E_COVID-19 Monthly Outcome Survey_Ipsos Omnibus COVID Questions.docx	Form and Instruction
Attachment F Attachment F: COVID-19 Monthly Outcome Survey – Consent Part A_Attachment F_COVID-19 Monthly Outcome Survey_Ipsos Consent Form.docx	Form and Instruction
Attachment G Attachment G: COVID-19 Monthly Outcome Survey – Communic Part A_Attachment G_COVID-19 Monthly Outcome Survey_Communications.docx	Form and Instruction

IC Title:

Monthly Outcome Survey (MOS)

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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	Attachment D	Attachment D: COVID-19 Monthly Outcome Survey â Questionnaire	Part A_Attachment D_COVID-19 Monthly Outcome Survey_Questionnaire.docx	Yes	Yes	Fillable Fileable
Form and Instruction	Attachment E	Attachment E: COVID-19 Monthly Outcome Survey â Ipsos Omnibus COVID Questions	Part A_Attachment E_COVID-19 Monthly Outcome Survey_Ipsos Omnibus COVID Questions.docx	Yes	Yes	Fillable Fileable
Form and Instruction	Attachment F	Attachment F: COVID-19 Monthly Outcome Survey â Consent Form	Part A_Attachment F_COVID-19 Monthly Outcome Survey_Ipsos Consent Form.docx	Yes	Yes	Fillable Fileable
Form and Instruction	Attachment G	Attachment G: COVID-19 Monthly Outcome Survey â Communications	Part A_Attachment G_COVID-19 Monthly Outcome Survey_Communications.docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 5,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	60,000	60,000
Annual IC Time Burden (Hours)	10,200	10,200
Annual IC Cost Burden (Dollars)	0	0

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.