Information Collection

Data Submission

IC 201169 under ICR 202108-0935-001 · OMB 0935-0196.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0935-0196 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Form #4 Data Submission	Form
Form #4 Example Screen Shots of Web Site Information Collection Attachment E - Medical Office Survey Data File Specifications.pdf	Form
Form #4 Example Screen Shots of Web Site Information Collection Attachment E - Medical Office Survey Data File Specifications.pdf	Form
Attachment F - SOPS Databases TEP List.docx Attachment F: Databases TEP List	IC Document
Attachment F - SOPS Databases TEP List.docx Attachment F: Databases TEP List	IC Document
Attachment D - Medical Office Data Submission Emails.docx Attachment D: Data Submission Emails	IC Document
Attachment D - Medical Office Data Submission Emails.docx Attachment D: Data Submission Emails	IC Document
Attachment G - Example Screenshots of MO SOPS Data Submission Website Information Collection.docx Attachment G: Example Screen Shots of Medical Office Survey on Patient Safety Culture Data Submission Web Site Information Colle	IC Document
Attachment G - Example Screenshots of MO SOPS Data Submission Website Information Collection.docx Attachment G: Example Screen Shots of Medical Office Survey on Patient Safety Culture Data Submission Web Site Information Colle	IC Document
60 Day FRN.pdf Federal Register Notice	IC Document
60 Day FRN.pdf Federal Register Notice	IC Document

IC Title:

Data Submission

Agency IC Tracking Number:

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	Form #4	Example Screen Shots of Web Site Information Collection	Attachment E - Medical Office Survey Data File Specifications.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 85

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: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	85	15	70
Annual IC Time Burden (Hours)	85	15	70
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachment F: Databases TEP List	Attachment F - SOPS Databases TEP List.docx	08/25/2021
Attachment D: Data Submission Emails	Attachment D - Medical Office Data Submission Emails.docx	08/25/2021
Attachment G: Example Screen Shots of Medical Office Survey on Patient Safety Culture Data Submission Web Site Information Collection	Attachment G - Example Screenshots of MO SOPS Data Submission Website Information Collection.docx	08/25/2021
Federal Register Notice	60 Day FRN.pdf	08/25/2021

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