Information Collection

Evaluation data for private-sector organizations

IC 199192 under ICR 201711-0920-011 · OMB 0920-0909.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0909 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-0909 Evaluation data for private-sector organizations	Form and Instruction
0920-0909 Evaluation Data Form Att 5A Data Dictionary_Evaluation Data Elements (Updated for 2018).docx	Form and Instruction
Attachment 5B Evaluation Data Elements (2011).docx Data Dictionary approved 2011	IC Document
Attachment 5C Evaluation Data Submission Web Application (screenshot).docx DPRP Data Web Application	IC Document

IC Title:

Evaluation data for private-sector organizations

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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	0920-0909	Evaluation Data Form	Att 5A Data Dictionary_Evaluation Data Elements (Updated for 2018).docx	NA	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,444

Number of Respondents for Small Entity: 540

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	Previously Approved
Annual Number of Responses for this IC	2,888	2,168	720
Annual IC Time Burden (Hours)	5,776	5,056	720
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Data Dictionary approved 2011	Attachment 5B Evaluation Data Elements (2011).docx	09/25/2014
DPRP Data Web Application	Attachment 5C Evaluation Data Submission Web Application (screenshot).docx	09/25/2014

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