Information Collection

Access to Electronic HCR during Outbreak and Assessment of State PHD Immunization Billing Reimbursement Projects

IC 211315 under ICR 201402-0920-018 · OMB 0920-0879.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0879 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-0879 Access to Electronic HCR during Outbreak and Assessment of State PHD Immunization Billing Reimbursement Projects	Form and Instruction
0920-0879 EHR Attachment A_Interview Guide HAI-Epi_041514 Attachment A_Interview Guide HAI-Epi_041514.docx	Form and Instruction
0920-0879 EHR Attachment B_Interview Guide Counsel Attachment B_Interview Guide Counsel.docx	Form and Instruction
0920-0879 EHR Attachment C_Instrument- Word- Phase 1 Attachment C_Interview Guide Informatics.docx	Form and Instruction
0920-0879 IZPHD Attachment B_Instrument- Web-Phase 1 Attachment B_Instrument- Web-Phase 1.docx	Form and Instruction
0920-0879 IZPHD Attachment C_Instrument- Word- Phase 1 Attachment C_Instrument- Word- Phase 1.docx	Form and Instruction
0920-0879 IZPHD Attachment D -Interview Instrument- Phase 2 Attachment D -Interview Instrument- Phase 2.docx	Form and Instruction
Supporting_Statement_A_041514.docx EHR Supporting_Statement_A_041514	IC Document
Supporting_Statement_B_041514.docx EHR Supporting_Statement_B_041514	IC Document
Attachment D_Intro Email_HAI_Epi.docx EHR Attachment D_Intro Email_HAI_Epi	IC Document
Attachment E- Invitation Email to HAI-EPI.docx EHR Attachment E- Invitation Email to HAI-EPI	IC Document
Attachment F-Invitation Email to Legal Counsel.docx EHR Attachment F-Invitation Email to Legal Counsel	IC Document
Attachment G- Invitation Email to Informatics Director.docx EHR Attachment G- Invitation Email to Informatics Director	IC Document
Attachment H- Reminder to HAI-EPI.docx EHR Attachment H- Reminder to HAI-EPI	IC Document
Attachment I-Reminder to Legal Counsel.docx EHR Attachment I-Reminder to Legal Counsel	IC Document
Attachment J-Reminder to Informatics Director.docx EHR Attachment J-Reminder to Informatics Director	IC Document
Statement A _IZ Funding.docx IZPHD Supporting Statement A _IZ Funding	IC Document
Statement B_IZ Funding.docx IAPHD Supporting Statement B_IZ Funding	IC Document
Attachment A_List HD Awardees.docx IZPHD Attachment A_List HD Awardees	IC Document
Attachment E Introductory Email- Phase 1.docx IZPHD Attachment E Introductory Email- Phase 1	IC Document
Attachment F-Reminder Email- Phase 1.docx IZPHD Attachment F-Reminder Email- Phase 1	IC Document
Attachment G -Follow-up Email- Phase 1.docx IZPHD Attachment G -Follow-up Email- Phase 1	IC Document
Attachment H- Interview Introductory Email- Phase 2.docx IZPHD Attachment H- Interview Introductory Email- Phase 2	IC Document
Attachment I- Interview Reminder Email- Phase 2.docx IZPHD Attachment I- Interview Reminder Email- Phase 2	IC Document
Attachment J- Interview Follow-up Email- Phase 2.docx IZPHD Attachment J- Interview Follow-up Email- Phase 2	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Access to Electronic HCR during Outbreak and Assessment of State PHD Immunization Billing Reimbursement Projects

Agency IC Tracking Number:

0920-14JS/0920-14TU

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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	0920-0879	EHR Attachment A_Interview Guide HAI-Epi_041514	Attachment A_Interview Guide HAI-Epi_041514.docx	Yes	No	Fillable Printable
Form and Instruction	0920-0879	EHR Attachment B_Interview Guide Counsel	Attachment B_Interview Guide Counsel.docx	Yes	No	Fillable Printable
Form and Instruction	0920-0879	EHR Attachment C_Instrument- Word- Phase 1	Attachment C_Interview Guide Informatics.docx	Yes	No	Fillable Printable
Form and Instruction	0920-0879	IZPHD Attachment B_Instrument- Web-Phase 1	Attachment B_Instrument- Web-Phase 1.docx	Yes	No	Fillable Printable
Form and Instruction	0920-0879	IZPHD Attachment C_Instrument- Word- Phase 1	Attachment C_Instrument- Word- Phase 1.docx	Yes	No	Fillable Printable
Form and Instruction	0920-0879	IZPHD Attachment D -Interview Instrument- Phase 2	Attachment D -Interview Instrument- Phase 2.docx	Yes	No	Fillable Printable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 110

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 50 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	110	110
Annual IC Time Burden (Hours)	61	61
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
EHR Supporting_Statement_A_041514	Supporting_Statement_A_041514.docx	04/18/2014
EHR Supporting_Statement_B_041514	Supporting_Statement_B_041514.docx	04/18/2014
EHR Attachment D_Intro Email_HAI_Epi	Attachment D_Intro Email_HAI_Epi.docx	04/18/2014
EHR Attachment E- Invitation Email to HAI-EPI	Attachment E- Invitation Email to HAI-EPI.docx	04/18/2014
EHR Attachment F-Invitation Email to Legal Counsel	Attachment F-Invitation Email to Legal Counsel.docx	04/18/2014
EHR Attachment G- Invitation Email to Informatics Director	Attachment G- Invitation Email to Informatics Director.docx	04/18/2014
EHR Attachment H- Reminder to HAI-EPI	Attachment H- Reminder to HAI-EPI.docx	04/18/2014
EHR Attachment I-Reminder to Legal Counsel	Attachment I-Reminder to Legal Counsel.docx	04/18/2014
EHR Attachment J-Reminder to Informatics Director	Attachment J-Reminder to Informatics Director.docx	04/18/2014
IZPHD Supporting Statement A _IZ Funding	Statement A _IZ Funding.docx	04/18/2014
IAPHD Supporting Statement B_IZ Funding	Statement B_IZ Funding.docx	04/18/2014
IZPHD Attachment A_List HD Awardees	Attachment A_List HD Awardees.docx	04/18/2014
IZPHD Attachment E Introductory Email- Phase 1	Attachment E Introductory Email- Phase 1.docx	04/18/2014
IZPHD Attachment F-Reminder Email- Phase 1	Attachment F-Reminder Email- Phase 1.docx	04/18/2014
IZPHD Attachment G -Follow-up Email- Phase 1	Attachment G -Follow-up Email- Phase 1.docx	04/18/2014
IZPHD Attachment H- Interview Introductory Email- Phase 2	Attachment H- Interview Introductory Email- Phase 2.docx	04/18/2014
IZPHD Attachment I- Interview Reminder Email- Phase 2	Attachment I- Interview Reminder Email- Phase 2.docx	04/18/2014
IZPHD Attachment J- Interview Follow-up Email- Phase 2	Attachment J- Interview Follow-up Email- Phase 2.docx	04/18/2014

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