Information Collection

Chronic Disease Self-Management Education Program

IC 206269 under ICR 201606-0985-002 · OMB 0985-0036.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0985-0036 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Chronic Disease Self-Management Education Program	Form and Instruction
1 Program Information Cover Sheet Program-Info-Cover-Sheet.pdf	Form and Instruction
2 Participant Information Survey Participant-Info-Survey.pdf	Form and Instruction
3 Attendance Log Attendance-Log.pdf	Form and Instruction
4 Host ImplementationInfoForm Host-Implementation InfoForm.pdf	Form and Instruction

IC Title:

Chronic Disease Self-Management Education Program

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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	1	Program Information Cover Sheet	Program-Info-Cover-Sheet.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	2	Participant Information Survey	Participant-Info-Survey.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	3	Attendance Log	Attendance-Log.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	4	Host ImplementationInfoForm	Host-Implementation InfoForm.pdf	Yes	Yes	Fillable Fileable

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 4,632

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	4,632	-28,056	4,632	28,056
Annual IC Time Burden (Hours)	586	-3,791	827	3,550
Annual IC Cost Burden (Dollars)	0	0	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.