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2021 Questionnaire
Medical Monitoring Project
OMB: 0920-0740
IC ID: 180565
OMB.report
HHS/CDC
OMB 0920-0740
ICR 202101-0920-006
IC 180565
( )
⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0740 can be found here:
2024-04-11 - Revision of a currently approved collection
Documents and Forms
Document Name
Document Type
2021 Questionnaire
Form and Instruction
MMP Questionnaire 2021 - English
Att 5a MMP 2021 Questionnaire English.pdf
Form and Instruction
MMP Questionnaire 2021 - English
Att 5a MMP 2021 Questionnaire English.pdf
Form and Instruction
MMP Questionnaire - Spanish
Att 5b MMP 2021 Questionnaire Spanish.pdf
Form and Instruction
MMP Questionnaire - Spanish
Att 5b MMP 2021 Questionnaire Spanish.pdf
Form and Instruction
Att 5c MMP 2018 Questionnaire English.pdf
MMP Questionnaire 2018
IC Document
Att 5c MMP 2018 Questionnaire English.pdf
MMP Questionnaire 2018
IC Document
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
2021 Questionnaire
Agency IC Tracking Number:
0920-0740
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
none
MMP Questionnaire 2021 - English
Att 5a MMP 2021 Questionnaire English.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
none
MMP Questionnaire - Spanish
Att 5b MMP 2021 Questionnaire Spanish.pdf
Yes
Yes
Fillable Fileable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Public Health Monitoring
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
7,760
Number of Respondents for Small Entity:
7,520
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
100 %
Approved
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
7,760
0
0
0
0
7,760
Annual IC Time Burden (Hours)
5,173
0
-647
0
0
5,820
Annual IC Cost Burden (Dollars)
134,015
0
7,314
0
0
126,701
Documents for IC
Title
Document
Date Uploaded
MMP Questionnaire 2018
Att 5c MMP 2018 Questionnaire English.pdf
01/19/2021
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.