Information Collection

Medical Office SOPS Data Use Agreement

IC 201168 under ICR 202504-0935-001 · OMB 0935-0196.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Form #3 Medical Office SOPS Data Use Agreement	Form and Instruction
Form Form #3 Medical Office SOPS Data Use Agreement Medical Office SOPS Data Use Agreement	Form and Instruction
Form #3 Medical Office SOPS Data Use Agreement Attachment B - Medical Office SOPS Data Use Agreement.docx	Form and Instruction
Form #3 Medical Office SOPS Data Use Agreement Attachment B - Medical Office SOPS Data Use Agreement.docx	Form and Instruction

IC Title:

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	Form #3				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

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

Percentage of Respondents Reporting Electronically: 95 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	85	-2,890	2,975
Annual IC Time Burden (Hours)	5	-243	248
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.

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