Chronic Disease Self-management Questionnaire

Evaluation of the Chronic Disease Self-Management Program in the US Affiliated Pacific Islands

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Document Name Document Type
Chronic Disease Self-management Questionnaire Form
Workshop Questionnaire Att. 4(a) Chronic Disease Self-Management Questionnaire (1).docx Form

Information Collection (IC) Details

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:

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 %

	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

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.