8a_MMP 2015 Interview Questionnaire (English)

Medical Monitoring Project

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0740 can be found here:

Documents and Forms

Document Name Document Type
Att 8a_2015 Questionnaire English.pdf Other-WORD
Att 8b_2015 Questionnaire Spanish.pdf Other-WORD
Att 8c_2014 Questionnaire English.pdf Other-WORD
Att 4d_MMP Recruitment Text E-mail Clean.docx 4d_Model Patient Recruitment Script IC Document
Att 10_Minimum Dataset Elements.docx Att 10_Minimum Data Elements IC Document
Att 9_MMP MRA Data Structure 2015.docx Att 9_Medical Record Abstraction Data Elements IC Document

Information Collection (IC) Details

IC Title:	8a_MMP 2015 Interview Questionnaire (English)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-WORD	Att 8a_2015 Questionnaire English.pdf	Yes	Yes	Fillable Printable
Other-WORD	Att 8b_2015 Questionnaire Spanish.pdf	Yes	Yes	Fillable Printable
Other-WORD	Att 8c_2014 Questionnaire English.pdf	Yes	Yes	Fillable Fileable Signable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 8,720	Number of Respondents for Small Entity: 7,520

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	8,720	1,200	7,520
Annual IC Time Burden (Hours)	6,540	6,164	376
Annual IC Cost Burden (Dollars)	142,376	142,376	0

Documents for IC

Title	Document	Date Uploaded
4d_Model Patient Recruitment Script	Att 4d_MMP Recruitment Text E-mail Clean.docx	03/30/2015
Att 10_Minimum Data Elements	Att 10_Minimum Dataset Elements.docx	03/30/2015
Att 9_Medical Record Abstraction Data Elements	Att 9_MMP MRA Data Structure 2015.docx	03/30/2015

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