Rapid ED Overdose data form - State HD

Drug Overdose Surveillance and Epidemiology (DOSE)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1268 can be found here:

Documents and Forms

Document Name Document Type
Rapid ED Overdose data form - State HD Form
Rapid ED Overdose Data Att D_Rapid_ED_Overdose_Data_Form_5_22_2019.xlsx Form

Information Collection (IC) Details

IC Title:	Rapid ED Overdose data form - State HD	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	Rapid ED Overdose Data	Att D_Rapid_ED_Overdose_Data_Form_5_22_2019.xlsx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 19	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	228	228
Annual IC Time Burden (Hours)	684	684
Annual IC Cost Burden (Dollars)	18,701	18,701

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.