Information Collection

Rapid ED Overdose data form - State HD

IC 236480 under ICR 201906-0920-001 · OMB 0920-1268.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
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

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:

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	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 %

table that charts list of burden
	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

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.