Information Collection

Diabetes Care SAQ

IC 191099 under ICR 201509-0935-001 · OMB 0935-0118.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0935-0118 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Form #1 Diabetes Care SAQ	Form and Instruction
Form #1 Attachment 19 -- HC Diabetes SAQ - Proxy 19-HC Diabetes SAQ - Proxy.docx	Form and Instruction
Form #2 Attachment 20 -- HC Diabetes SAQ - Self 20-HC Diabetes SAQ - Self.docx	Form and Instruction

IC Title:

Diabetes Care SAQ

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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	Form #1	Attachment 19 -- HC Diabetes SAQ - Proxy	19-HC Diabetes SAQ - Proxy.docx		Yes	Yes	Paper Only
Form and Instruction	Form #2	Attachment 20 -- HC Diabetes SAQ - Self	20-HC Diabetes SAQ - Self.docx		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 2,345

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	2,345	2,345
Annual IC Time Burden (Hours)	117	117
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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