Information Collection

Authorization Form for the MEPS-MPC Provider and Pharmacy Survey

IC 204197 under ICR 202406-0935-002 · OMB 0935-0118.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0935-0118 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 52 Authorization Form for the MEPS-MPC Provider and Pharmacy Survey	Form and Instruction
52 Permission Form for Medical Providers Attachment 52 -- Permission Form for Medical Providers.pdf	Form and Instruction
52 Permission Form for Medical Providers Attachment 52 -- Permission Form for Medical Providers.pdf	Form and Instruction
53 Permission Form for Pharmacies Attachment 53 -- Permission Form for Pharmicies.pdf	Form and Instruction
53 Permission Form for Pharmacies Attachment 53 -- Permission Form for Pharmicies.pdf	Form and Instruction

IC Title:

Authorization Form for the MEPS-MPC Provider and Pharmacy Survey

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 and Instruction	52	Permission Form for Medical Providers	Attachment 52 -- Permission Form for Medical Providers.pdf		Yes	Yes	Fillable Fileable
Form and Instruction	53	Permission Form for Pharmacies	Attachment 53 -- Permission Form for Pharmicies.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 7,386

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	Previously Approved
Annual Number of Responses for this IC	38,407	-16,348	54,755
Annual IC Time Burden (Hours)	1,920	-818	2,738
Annual IC Cost Burden (Dollars)	0	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.