Information Collection

Medical Office SOPS Data Submission Emails

IC 201169 under ICR 202504-0935-001 · OMB 0935-0196.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Form #4 Medical Office SOPS Data Submission Emails	Form and Instruction
Form Form #4 Medical Office Data Submission Emails Medical Office SOPS Data Submission Emails	Form and Instruction
Form #4 Medical Office Data Submission Emails Attachment D - Medical Office Data Submission Emails.docx	Form and Instruction
Form #4 Medical Office Data Submission Emails Attachment D - Medical Office Data Submission Emails.docx	Form and Instruction
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:

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	Form #4				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	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	85	85
Annual IC Time Burden (Hours)	85	85
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachment F: Databases TEP List		08/25/2021
Attachment D: Data Submission Emails		08/25/2021
Attachment G: Example Screen Shots of Medical Office Survey on Patient Safety Culture Data Submission Web Site Information Collection		08/25/2021
Federal Register Notice		08/25/2021

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

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