Information Collection

Heart Disease and Stroke Prevention Programs

IC 7147 under ICR 201103-0920-002 · OMB 0920-0679.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
CHB MIS Data Collection Tool.doc	Other-WORD
Attachment 6. Proposed Revisions.doc	Other-WORD
1 DHDSP MIS SCREEN SHOTS Attachment 4. DHDSP MIS Screen Shots.docx	Form and Instruction
Attachment 5. Usability Results.doc Usability Testing Results	IC Document

IC Title:

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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-WORD			CHB MIS Data Collection Tool.doc	No	No	Fillable Printable
Other-WORD			Attachment 6. Proposed Revisions.doc	No	No	Fillable Printable
Form and Instruction	1	DHDSP MIS SCREEN SHOTS	Attachment 4. DHDSP MIS Screen Shots.docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 42

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	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	84	16	68
Annual IC Time Burden (Hours)	504	96	408
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Usability Testing Results	Attachment 5. Usability Results.doc	01/16/2008

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