Formative Research to Identify Common and Unique Barriers to the Exchange of Hospitalization and ED Data

CDC/ATSDR Formative Research and Tool Development

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Document Name Document Type
Formative Research to Identify Common and Unique Barriers to the Exchange of Hospitalization and ED Data Form
Survey AttA2_Survey instrument (screenshots).pdf Form
Survey - word AttA1_Survey Instrument (word).docx Form
Survey prenotice AttB1_Prenotice.DOCX Form
GenICRequest.pdf genIC Request IC Document
AttB2_Survey Invitation Email.DOCX Survey Invitation IC Document
AttB3_Reminder Email.docx Reminder Email IC Document
AttB4_Survey Closing Email.DOCX Survey Closing Email IC Document
AttC_RDF.pdf Research Determination IC Document
SSA_Formative Research to Identify Common and ED Data.docx Supporting Statement A IC Document
SSB_Formative Research to Identify Common and ED Data.docx Supporting Statement B IC Document

Information Collection (IC) Details

IC Title:	Formative Research to Identify Common and Unique Barriers to the Exchange of Hospitalization and ED Data	Agency IC Tracking Number:	0920-1154-19BEA

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	none	Survey	AttA2_Survey instrument (screenshots).pdf	Yes	Yes	Fillable Fileable
Form	none	Survey - word	AttA1_Survey Instrument (word).docx	Yes	Yes	Fillable Fileable
Form	none	Survey prenotice	AttB1_Prenotice.DOCX	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 52	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	52	52
Annual IC Time Burden (Hours)	113	113
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
genIC Request	GenICRequest.pdf	07/29/2019
Survey Invitation	AttB2_Survey Invitation Email.DOCX	07/29/2019
Reminder Email	AttB3_Reminder Email.docx	07/29/2019
Survey Closing Email	AttB4_Survey Closing Email.DOCX	07/29/2019
Research Determination	AttC_RDF.pdf	07/29/2019
Supporting Statement A	SSA_Formative Research to Identify Common and ED Data.docx	07/29/2019
Supporting Statement B	SSB_Formative Research to Identify Common and ED Data.docx	07/29/2019

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