Information Collection

Diabetes Primary Prevention

IC 214369 under ICR 201205-0920-001 · OMB 0920-0222.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
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

IC Title:

Diabetes Primary Prevention

Agency IC Tracking Number:

15IS

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
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 %

table that charts list of burden
	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

table that charts IC Documents
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.