Information Collection

Core Clinical Characteristics Forms-Baseline and Follow-up

IC 7691 under ICR 201109-0930-005 · OMB 0930-0276.

Documents and Forms

Document Name Document Type
Form Baseline Core Clinical Characteristics Forms-Baseline and Follow-up Form and Instruction
Baseline Baseline Attachment C.1 CDS Baseline Form_2.doc Form and Instruction
Followup Followup Attachment C.2 CDS Follow-Up Form_2.doc Form and Instruction
Attachment J_O.pdf Concent Forms IC Document
Attachment A_B.pdf Design/Screen Shots IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Core Clinical Characteristics Forms-Baseline and Follow-up	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	Baseline	Baseline	Attachment C.1 CDS Baseline Form_2.doc		Yes	Yes	Paper Only
Form and Instruction	Followup	Followup	Attachment C.2 CDS Follow-Up Form_2.doc		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 3,243	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	12,972	-406,748	419,720
Annual IC Time Burden (Hours)	4,281	-7,052	11,333
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Concent Forms	Attachment J_O.pdf	09/01/2011
Design/Screen Shots	Attachment A_B.pdf	09/01/2011

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