Information Collection

Well-Integrated Screening and Evaluation for Women Across the Nation (WISEWOMAN) Reporting System

IC 37802 under ICR 201905-0920-005 · OMB 0920-0612.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0612 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Attachment 3 WISEWOMAN MDE Version 9 0.pdf	Instruction
0612 Att 4a Web Portal Login Screenshot Final.png	Other-Screenshot
0612 Att 4b Web Portal Submission Screenshot Final.png	Other-Screenshot
0920-0612 WISEWOMAN Program MDE Manual Version 9.0 July 2013 WISEWOMAN MDEs.pdf	Form and Instruction
Attachment 4 Screen Shots of Portal 09 24 2013.pdf Attachment 4 Screen Shots of Portal	IC Document
Exhibits.docx Exhibits 1. Overview of Proposed Improvements	IC Document
OMB Change Request Summary 04.06.18.docx Request for Nonmaterial/Non-substantive Change to an OMB Approved	IC Document

IC Title:

Well-Integrated Screening and Evaluation for Women Across the Nation (WISEWOMAN) Reporting System

Agency IC Tracking Number:

0920-0612 (18YZ)

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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Screenshot			0612 Att 4a Web Portal Login Screenshot Final.png	Yes	Yes	Fillable Fileable
Other-Screenshot			0612 Att 4b Web Portal Submission Screenshot Final.png	Yes	Yes	Fillable Fileable
Instruction			Attachment 3 WISEWOMAN MDE Version 9 0.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	0920-0612	WISEWOMAN Program MDE Manual Version 9.0 July 2013	WISEWOMAN MDEs.pdf	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 21

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	42	42
Annual IC Time Burden (Hours)	1,008	1,008
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachment 4 Screen Shots of Portal	Attachment 4 Screen Shots of Portal 09 24 2013.pdf	10/29/2013
Exhibits 1. Overview of Proposed Improvements	Exhibits.docx	04/10/2018
Request for Nonmaterial/Non-substantive Change to an OMB Approved	OMB Change Request Summary 04.06.18.docx	04/10/2018

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