Data Verification Form

Million Hearts Hypertension Control Challenge

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0976 can be found here:

Documents and Forms

Document Name Document Type
Data Verification Form Form and Instruction
Att 4 Revised Data Verification Form track changes_08072017.docm Other-This is a reference document t
Revised Data Verification Form_08072017 Att 4 Revised Data Verification Form clean_08072017.docm Form and Instruction

Information Collection (IC) Details

IC Title:	Data Verification Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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	n/a	Revised Data Verification Form_08072017	Att 4 Revised Data Verification Form clean_08072017.docm		Yes	Yes	Fillable Fileable
Other-This is a reference document that shows changes in track-changes format.			Att 4 Revised Data Verification Form track changes_08072017.docm		No		Paper Only

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 40	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 %

	Approved	Previously Approved
Annual Number of Responses for this IC	40	40
Annual IC Time Burden (Hours)	40	40
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.