Information Collection

Clinical Data Elements (CCDE)

IC 179134 under ICR 201304-0920-004 · OMB 0920-0745.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Attachment 3b. CCDE Data Definition Table.docx	Other-Data Definition Table
Attachment 3a. CCDE Submission Web portal.doc	Other-Entry to Web Portal Screenshot
Attachment 3c. CCDE Data Users Manual.docx Data Users Manual	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

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-Data Definition Table			Attachment 3b. CCDE Data Definition Table.docx		Yes	Yes	Fillable Fileable
Other-Entry to Web Portal Screenshot			Attachment 3a. CCDE Submission Web portal.doc		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 29

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	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	10,875	1,125	9,750
Annual IC Time Burden (Hours)	2,719	281	2,438
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Data Users Manual	Attachment 3c. CCDE Data Users Manual.docx	03/14/2013

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