Information Collection

Interviews

IC 233373 under ICR 201810-0930-001 · OMB 0930-0382.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form EHR Questionnaire Interviews	Form and Instruction
EHR Questionnaire EHR Questionnaire Attachment A EHR Questionnaire.pdf	Form and Instruction
Attachment B Consent Form v_5-7-18_FINAL.DOCX Consent Form	IC Document

IC Title:

Interviews

Agency IC Tracking Number:

Is this a Common Form? No

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	EHR Questionnaire	EHR Questionnaire	Attachment A EHR Questionnaire.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 80

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

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	80	80
Annual IC Time Burden (Hours)	40	40
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Consent Form	Attachment B Consent Form v_5-7-18_FINAL.DOCX	10/02/2018

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