Information Collection Request

[NCHHSTP] Medical Monitoring Project

ICR 202503-0920-027 · OMB 0920-0740 · Active

Forms and Documents

Forms and supporting documents for this ICR
DocumentTypeStatusAvailability
Recruitment script Form and Instruction Unchanged Available
Model Patient Recruitment Script - Facility Form and Instruction Unchanged Missing upstream
Form 0920-25-0058 MMP Questionnaire _SPANISH Form Modified Available
Form 0920-25-0058 MMP Questionnaire Form Modified Available
2024 Programming Questionnaire - English Form and Instruction Modified Available
Interview Questionnaire Form and Instruction Modified Repair queued
Justification Memo for Nonsubstantive Change Req_MMP 0920-0740.docx Justification for No Material/Nonsubstantive Change Uploaded 2025-03-24 Available
Justification Memo for Nonsubstantive Change Req_MMP 0920-0740.docx Justification for No Material/Nonsubstantive Change Uploaded 2025-03-24 Repair queued
Att 2b_MMP MRA Data Structure_clean.docx Supplementary Document Uploaded 2025-03-24 Available
Att 2b_MMP MRA Data Structure_clean.docx Supplementary Document Uploaded 2025-03-24 Repair queued
Att 17 Sample sizes.docx Supplementary Document Uploaded 2024-04-10 Available
Att 17 Sample sizes.docx Supplementary Document Uploaded 2024-04-10 Missing upstream
Att 16 Agreement To Abide by Restrictions.docx Supplementary Document Uploaded 2024-04-10 Available
Att 16 Agreement To Abide by Restrictions.docx Supplementary Document Uploaded 2024-04-10 Missing upstream
Att 15 DCC ATO.pdf Supplementary Document Uploaded 2024-04-10 Available
Att 15 DCC ATO.pdf Supplementary Document Uploaded 2024-04-10 Repair queued
Att 14 Project Determination MMP.pdf Supplementary Document Uploaded 2024-04-10 Available
Att 14 Project Determination MMP.pdf Supplementary Document Uploaded 2024-04-10 Repair queued
Att 13 Assurance of Confidentiality.docx Supplementary Document Uploaded 2024-04-10 Available
Att 13 Assurance of Confidentiality.docx Supplementary Document Uploaded 2024-04-10 Repair queued
Att 12 WISMS PIA_signed.pdf Supplementary Document Uploaded 2024-04-10 Available
Att 12 WISMS PIA_signed.pdf Supplementary Document Uploaded 2024-04-10 Repair queued
Att 11 Consultations Conducted Before 2010.docx Supplementary Document Uploaded 2024-04-10 Available
Att 11 Consultations Conducted Before 2010.docx Supplementary Document Uploaded 2024-04-10 Repair queued
Att 10 MMP Bibliography.docx Supplementary Document Uploaded 2024-04-10 Available
Att 10 MMP Bibliography.docx Supplementary Document Uploaded 2024-04-10 Repair queued
Att 9 MMP_CrossJuris_Agreement_MMP 2024_Cycle.docx Supplementary Document Uploaded 2024-04-10 Available
Att 9 MMP_CrossJuris_Agreement_MMP 2024_Cycle.docx Supplementary Document Uploaded 2024-04-10 Repair queued
Att 8d Recruitment Text E-mail.docx Supplementary Document Uploaded 2024-04-10 Available
Att 8d Recruitment Text E-mail.docx Supplementary Document Uploaded 2024-04-10 Repair queued
Att 8b Recruitment Script Project Staff.docx Supplementary Document Uploaded 2024-04-10 Available
Att 8b Recruitment Script Project Staff.docx Supplementary Document Uploaded 2024-04-10 Repair queued
Att 8a Model Recruitment Letter.docx Supplementary Document Uploaded 2024-04-10 Available
Att 8a Model Recruitment Letter.docx Supplementary Document Uploaded 2024-04-10 Repair queued
Att 7 References 2023 12 12 clean.docx Supplementary Document Uploaded 2024-02-14 Available
Att 7 References 2023 12 12 clean.docx Supplementary Document Uploaded 2024-02-14 Missing upstream
Att 6 MMP MRA Data Structure _2024.docx Supplementary Document Uploaded 2024-02-14 Available
Att 6 MMP MRA Data Structure _2024.docx Supplementary Document Uploaded 2024-02-14 Missing upstream
Att 5d Summary of changes to questionnaire 2024 2023 07 25.docx Supplementary Document Uploaded 2024-02-14 Available
Att 5d Summary of changes to questionnaire 2024 2023 07 25.docx Supplementary Document Uploaded 2024-02-14 Repair queued
Att 5c MMP 2021 Questionnaire English.pdf Supplementary Document Uploaded 2024-02-14 Available
Att 5c MMP 2021 Questionnaire English.pdf Supplementary Document Uploaded 2024-02-14 Repair queued
Att 4 MMP Minimum Dataset Elements.docx Supplementary Document Uploaded 2024-02-14 Available
Att 4 MMP Minimum Dataset Elements.docx Supplementary Document Uploaded 2024-02-14 Repair queued
Att 3 MMP 2024-2026 Model Consent.docx Supplementary Document Uploaded 2024-02-14 Available
Att 3 MMP 2024-2026 Model Consent.docx Supplementary Document Uploaded 2024-02-14 Repair queued
Att 2_60-Day FRN.pdf Supplementary Document Uploaded 2024-02-14 Available
Att 2_60-Day FRN.pdf Supplementary Document Uploaded 2024-02-14 Repair queued
Att 1_Sect 301 PHSA.PDF Supplementary Document Uploaded 2024-02-14 Available
Att 1_Sect 301 PHSA.PDF Supplementary Document Uploaded 2024-02-14 Repair queued
MMP-SSB_2023 12 12 clean.docx Supporting Statement B Uploaded 2024-02-14 Available
MMP-SSB_2023 12 12 clean.docx Supporting Statement B Uploaded 2024-02-14 Repair queued
MMP-SSA_2024 02 16 clean amended.docx Supporting Statement A Uploaded 2024-05-15 Available
MMP-SSA_2024 02 16 clean amended.docx Supporting Statement A Uploaded 2024-05-15 Repair queued

IC Document Collections

Information collection document groups
IC IDCollectionTypeStatusForm
180569 Pull Medical Records Instruction Unchanged
180568 Lookup Contact Information Instruction Unchanged
180566 Model Patient Recruitment Script - Facility Form and Instruction UnchangedRecruitment script
180566 Model Patient Recruitment Script - Facility Form and Instruction Unchanged
180565 Interview Questionnaire Form ModifiedMMP Questionnaire _SPANISH
180565 Interview Questionnaire Form ModifiedMMP Questionnaire
180565 Interview Questionnaire Form and Instruction Modified2024 Programming Questionnaire - English
180565 Interview Questionnaire Form and Instruction Modified

ICR Details

Reginfo record details
table that charts list comparision
  Inventory as of this Action Requested Previously Approved
05/31/2027 05/31/2027 05/31/2027
18,430 0 18,430
5,707 0 5,707
147,364 0 147,364





Reginfo record details
4
table that charts list of burden
IC Title Form No. Form Name
Interview Questionnaire none, 0920-25-0058, 0920-25-0058 ,   ,  
Lookup Contact Information
Model Patient Recruitment Script - Facility none
Pull Medical Records

table that charts list of burden
  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 18,430 18,430 0 0 0 0
Annual Time Burden (Hours) 5,707 5,707 0 0 0 0
Annual Cost Burden (Dollars) 147,364 147,364 0 0 0 0


Reginfo record details
  No