Information Collection

Chronic Disease Self-management Questionnaire

IC 234803 under ICR 201901-0920-012 · OMB 0920-1265.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1265 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Chronic Disease Self-management Questionnaire	Form
Workshop Questionnaire Att. 4(a) Chronic Disease Self-Management Questionnaire (1).docx	Form

IC Title:

Chronic Disease Self-management Questionnaire

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	none	Workshop Questionnaire	Att. 4(a) Chronic Disease Self-Management Questionnaire (1).docx		No		Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 190

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	380	380
Annual IC Time Burden (Hours)	63	63
Annual IC Cost Burden (Dollars)	380	380

Documents for IC

table that charts IC Documents
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.