Information Collection

First Home Visit Form: Diabetes or Hypertension or Hypertension and Diabetes

IC 200850 under ICR 201201-0990-005 · OMB 0990-0402.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0990-0402 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
0990-PCCC_First Home Visit Form.docx	Other-survey

IC Title:

First Home Visit Form: Diabetes or Hypertension or Hypertension and Diabetes

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

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
Other-survey			0990-PCCC_First Home Visit Form.docx		No	No	Printable Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 200

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	200	200
Annual IC Time Burden (Hours)	133	133
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.