Information Collection

Authorization Form for the MEPS-MPC Provider and Pharmacy Survey

IC 204197 under ICR 202603-0935-001 · OMB 0935-0118.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 51 Permission Form for Medical Providers Authorization Form for the MEPS-MPC Provider and Pharmacy Survey	Form and Instruction
Form 52 Permission Form for Pharmacies Authorization Form for the MEPS-MPC Provider and Pharmacy Survey	Form and Instruction
51 Permission Form for Medical Providers Attachment 51 -- Permission Form for Medical Providers.pdf	Form and Instruction
52 Permission Form for Pharmacies Attachment 52 -- Permission Form for Pharmacies.pdf	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	51				Yes	Yes	Fillable Fileable
Form and Instruction	52				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 17,388

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	62,597	24,190	38,407
Annual IC Time Burden (Hours)	3,130	1,210	1,920
Annual IC Cost Burden (Dollars)	204,452	204,452	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.

Something went wrong when downloading this file. If you have any questions, please send an email to [email protected].