Diabetes Primary Prevention

NCHS Questionnaire Design Research Laboratory

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0222 can be found here:

Documents and Forms

Document Name Document Type
Diabetes Primary Prevention Form
Questionnaire Attach 1 Diabetes Qnne 121914.docx Form
Screener Attach 3a &3b screener 121914.docx Form
Attach 2 Diabetes AdFlyer 121914.docx Flyer IC Document
Attach 4 Diabetes Informed Consent 121914.docx Informed Consent IC Document
0920-0222 QDRL Diabetes 10day ltr 120414.docx Diabetes 10 Day Letter IC Document

Information Collection (IC) Details

IC Title:	Diabetes Primary Prevention	Agency IC Tracking Number:	15IS

IC Status: New

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	none	Questionnaire	Attach 1 Diabetes Qnne 121914.docx		No		Paper Only
Form	none	Screener	Attach 3a &3b screener 121914.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 117	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	117	117
Annual IC Time Burden (Hours)	51	51
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Flyer	Attach 2 Diabetes AdFlyer 121914.docx	12/19/2014
Informed Consent	Attach 4 Diabetes Informed Consent 121914.docx	12/19/2014
Diabetes 10 Day Letter	0920-0222 QDRL Diabetes 10day ltr 120414.docx	12/19/2014

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