Dialysis–related Cardiac Arrest Data Collection Tool for data received through Case Finding

Undetermined Cause of Cardiac Arrest during Hemodialysis — Connecticut 2015-2016

Documents and Forms

Document Name Document Type
Dialysis–related Cardiac Arrest Data Collection Tool for data received through Case Finding Form and Instruction
Dialysis-related Cardiac Arrest Data Collection Tool for Att 6 - Data collection for case finding.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Dialysis–related Cardiac Arrest Data Collection Tool for data received through Case Finding	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	NA	Dialysis-related Cardiac Arrest Data Collection Tool for data received through Case Finding	Att 6 - Data collection for case finding.docx	NA	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title: 09-20-0136 Epidemiologic Studies and Surveillance of Disease Problems	FR Citation: 57 FR 62812

Number of Respondents: 10	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	10	10
Annual IC Time Burden (Hours)	5	5
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.