Information Collection

Core Clinical Characteristics Forms-Baseline and Follow-up

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

Documents and Forms

Documents and forms in this information collection
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

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

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
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 %

table that charts list of burden
	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

table that charts IC Documents
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.