Information Collection

Sub-study #7_Development of Consensus Measures of Distress for the Grid Enabled Measures-Distress Measurement (GEM-DM) Workspace

IC 209051 under ICR 201302-0925-007 · OMB 0925-0589.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0589 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Sub-study #7_Development of Consensus Measures of Distress for the Grid Enabled Measures-Distress Measurement (GEM-DM) Workspace	Form and Instruction
1 GEM-DM Survey Attachment A_GEM-DM Survey 8-27-2013.doc	Form and Instruction
Gen IC Form_GEM-DM.doc Gen IC Form_GEM-DM	IC Document
miniSSA_GEM-DM_2013 9-12-2013.doc miniSSA_GEM-DM_2013 9-12-2013	IC Document
miniSSB_GEM-DM_9_12_13.docx miniSSB_GEM-DM_9_12_13	IC Document
Attachment B_Email Invite 8-6-2013.doc Attachment B_Email Invite 8-6-2013	IC Document
Attachment C_OHSR Exempt.pdf Attachment C_OHSR Exempt	IC Document
Attachment D_Measure info.doc Attachment D_Measure info	IC Document

IC Title:

Sub-study #7_Development of Consensus Measures of Distress for the Grid Enabled Measures-Distress Measurement (GEM-DM) Workspace

Agency IC Tracking Number:

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 and Instruction	1	GEM-DM Survey	Attachment A_GEM-DM Survey 8-27-2013.doc		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title: "Records of Participants in Programs and Respondents in Surveys Used to Evaluate Programs of the Public Health Service, HHS/PHS/NIH/OD"

FR Citation: 67 FR 60743

Number of Respondents: 100

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 New Statute	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA	Previously Approved
Annual Number of Responses for this IC	100	0	0	0	0	0
Annual IC Time Burden (Hours)	25	0	0	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Gen IC Form_GEM-DM	Gen IC Form_GEM-DM.doc	09/12/2013
miniSSA_GEM-DM_2013 9-12-2013	miniSSA_GEM-DM_2013 9-12-2013.doc	09/12/2013
miniSSB_GEM-DM_9_12_13	miniSSB_GEM-DM_9_12_13.docx	09/12/2013
Attachment B_Email Invite 8-6-2013	Attachment B_Email Invite 8-6-2013.doc	09/12/2013
Attachment C_OHSR Exempt	Attachment C_OHSR Exempt.pdf	09/12/2013
Attachment D_Measure info	Attachment D_Measure info.doc	09/12/2013

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