Information Collection

Emergency Department Discharge Tool (EDT)

IC 210531 under ICR 201402-0935-002 · OMB 0935-0217.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Emergency Department Discharge Tool (EDT)	Form and Instruction
1 Emergency Department Discharge Tool (EDT) Attachment A - ED Discharge High Risk Screening Checklist Tool 2013.12.13.docx	Form and Instruction
Attachment B - EDT User Guide 2013.12.13.docx Attachment B - EDT User Guide 2013	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

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	Emergency Department Discharge Tool (EDT)	Attachment A - ED Discharge High Risk Screening Checklist Tool 2013.12.13.docx		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 900

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	900	900
Annual IC Time Burden (Hours)	300	300
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachment B - EDT User Guide 2013	Attachment B - EDT User Guide 2013.12.13.docx	02/21/2014

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