Information Collection

Intervention Minimum Data Elements (MDEs)

IC 191866 under ICR 201101-0920-002 · OMB 0920-0612.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0612 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Attachment 4. InterventionMDE_v700.doc	Instruction
Revised Intervention MDEs Attachment4Intervention(revised).docx	Form

IC Title:

Intervention Minimum Data Elements (MDEs)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

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
Instruction			Attachment 4. InterventionMDE_v700.doc		Yes	Yes	Fillable Printable
Form	none	Revised Intervention MDEs	Attachment4Intervention(revised).docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 21

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	42	42
Annual IC Time Burden (Hours)	336	336
Annual IC Cost Burden (Dollars)	0	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.