Information Collection

Combined MDE for Screening and Assessment MDE and Lifestyle Program MDE

IC 37802 under ICR 201310-0920-006 · OMB 0920-0612.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0612 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-0612 Attachment 3a WISEWOMAN MDE Version 9 Combined MDE for Screening and Assessment MDE and Lifestyle Program MDE	Form and Instruction
Form 0920-0612 Attachment 3b Summary of MDE Changes Combined MDE for Screening and Assessment MDE and Lifestyle Program MDE	Form and Instruction
0920-0612 Attachment 3a WISEWOMAN MDE Version 9 Attachment 3a WISEWOMAN MDE Version 9 00_08 08 2013.docx	Form and Instruction
0920-0612 Attachment 3b Summary of MDE Changes Attachment 3b Summary of MDE Changes 091913IV.docx	Form and Instruction
Attachment 4 Screen Shots of Portal 09 24 2013.pdf Attachment 4 Screen Shots of Portal	IC Document

IC Title:

Combined MDE for Screening and Assessment MDE and Lifestyle Program MDE

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
Form and Instruction	0920-0612				Yes	Yes	Fillable Fileable
Form and Instruction	0920-0612				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 21

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	42	0	42
Annual IC Time Burden (Hours)	1,008	336	672
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachment 4 Screen Shots of Portal		10/29/2013

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

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