Information Collection

AIRS Emergency Department Visits Reporting

IC 220722 under ICR 201904-0920-002 · OMB 0920-0853.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0853 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-0853 AIRS Emergency Department Visits Reporting	Form
0920-0853 STATE [Year] Emergency Department Data Att3b_AIRS ED Visits Reporting Form.xlsx	Form
Att3d1_AIRS Instructions_HD_ED_Data_clean.docx Instructions for Asthma State Awardees	IC Document
Att3b1_AIRS ED Visits Reporting Example.xlsx Att eb1. AIRS ED Visits Reporting Example	IC Document

IC Title:

AIRS Emergency Department Visits Reporting

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

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	0920-0853	STATE [Year] Emergency Department Data	Att3b_AIRS ED Visits Reporting Form.xlsx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 25

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	Previously Approved
Annual Number of Responses for this IC	25	2	23
Annual IC Time Burden (Hours)	13	1	12
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Instructions for Asthma State Awardees	Att3d1_AIRS Instructions_HD_ED_Data_clean.docx	04/04/2019
Att eb1. AIRS ED Visits Reporting Example	Att3b1_AIRS ED Visits Reporting Example.xlsx	04/04/2019

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