Information Collection

MTM Partner Site-Level Interview

IC 241438 under ICR 202110-0920-012 · OMB 0920-1311.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
MTM Partner Site-Level Interview	Form and Instruction
MTM Partner Site Interview Guide Att 4h. MTM Partner Site Interview Guide B4.docx	Form and Instruction
MTM Partner Site Interview Guide Att 4h. MTM Partner Site Interview Guide B4.docx	Form and Instruction
MTM Partner Site Interview Guide for Pharmacists Att 4i. MTM Partner Site Interview Guide B4.docx	Form and Instruction
MTM Partner Site Interview Guide for Pharmacists Att 4i. MTM Partner Site Interview Guide B4.docx	Form and Instruction

IC Title:

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	n/a	MTM Partner Site Interview Guide	Att 4h. MTM Partner Site Interview Guide B4.docx		No		Paper Only
Form and Instruction	n/a	MTM Partner Site Interview Guide for Pharmacists	Att 4i. MTM Partner Site Interview Guide B4.docx		No		Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 7

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	7	7
Annual IC Time Burden (Hours)	7	7
Annual IC Cost Burden (Dollars)	560	560

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.