Information Collection

Chronic Disease Self-Management Education Program

IC 206269 under ICR 201908-0985-003 · OMB 0985-0036.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0985-0036 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Chronic Disease Self-Management Education Program	Form and Instruction
Program Information Cover Sheet 0036 Program.Info.Cover.Sheet.Revised.2.docx	Form and Instruction
Participant Information Survey 0036 CDSME Participant Survey - Revised Sheet v3.docx	Form and Instruction
Attendance Log 0036 CDSME.Attendance.Log.Revised.1.docx	Form and Instruction

IC Title:

Chronic Disease Self-Management Education Program

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

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
Form and Instruction	NA	Program Information Cover Sheet	0036 Program.Info.Cover.Sheet.Revised.2.docx	Yes	Yes	Fillable Fileable
Form and Instruction	NA	Participant Information Survey	0036 CDSME Participant Survey - Revised Sheet v3.docx	Yes	Yes	Fillable Fileable
Form and Instruction	NA	Attendance Log	0036 CDSME.Attendance.Log.Revised.1.docx	Yes	Yes	Fillable Fileable

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 14,915

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	14,915	0	10,283	4,632
Annual IC Time Burden (Hours)	3,375	2,789	0	586
Annual IC Cost Burden (Dollars)	0	0	0	0

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.