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

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

Information Collection (IC) Details

View Information Collection (IC)

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:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	51	Permission Form for Medical Providers	Attachment 51 -- Permission Form for Medical Providers.pdf		Yes	Yes	Fillable Fileable
Form and Instruction	52	Permission Form for Pharmacies	Attachment 52 -- Permission Form for Pharmacies.pdf		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 %

	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

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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