Information Collection

Disability and Health Data System Evaluaton Survey

IC 230837 under ICR 201610-0920-009 · OMB 0920-1154.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1154 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-1154 Disability and Health Data System Evaluaton Survey	Form and Instruction
0920-1154 Disability and Halth Data System Evaulation Survey Attachment 1_DHDS 2018 Evaluation Survey.docx	Form and Instruction
GenICRequest_DHDS 2018 Evaluation Survey_03282018.tfs4.docx Request for Approval	IC Document

IC Title:

Disability and Health Data System Evaluaton Survey

Agency IC Tracking Number:

0920-1154 (18WS)

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	0920-1154	Disability and Halth Data System Evaulation Survey	Attachment 1_DHDS 2018 Evaluation Survey.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 2,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	2,000	2,000
Annual IC Time Burden (Hours)	167	167
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Request for Approval	GenICRequest_DHDS 2018 Evaluation Survey_03282018.tfs4.docx	03/29/2018

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