0920-1154 Drexel -demographic Intake Form

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PART II: PAPERWORK REDUCTION ACT SUBMISSION WORKSHEET
Please fill out and include with your Information Collection Request (ICR) submission to the Information
Collection Review Office (ICRO). A separate Part II Worksheet is required for each information
collection instrument or activity including recruitment, records abstraction, training, spirometry testing,
etc. This information must match information in the Supporting Statement and Burden Table (Sections
12.A & 12.B). Be sure to provide the Title and Attachment ID for the instrument associated with each
Part II Worksheet.

Information Collection (IC) Title: Home Assessments for Patients & Families with Special Health Care
Needs:
Developing Tools, Communication Strategies, and Standards
__________________________________________________________
F- Intake Form
Attachment ID: _____________________
0920-1154
Agency IC Tracking Number: ______________
Is this a Common Form?
Yes
No

Obligation to Respond (check one)

Voluntary
Required to obtain or retain benefits
Mandatory

Frequency of Reporting (check all that apply)
Hourly (40 per week)
Daily
Weekly
Monthly
Quarterly
Yearly
Every Decade
Semi-Annually
Biennially
Once
Occasionally

Code of Federal Regulation (CFR) Citation(s) for this Information collection form if applicable:
Title: __________________________________________________ Part: _________ Section: _________
Title: __________________________________________________ Part: _________ Section: _________
Title: __________________________________________________ Part: _________ Section: _________

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Federal Enterprise Architecture Business Reference Model (select one Services for Citizens Line of
Business and one Sub-Function from its group)
Services for Citizens Line of Business
Disaster Management

Sub-Function
Disaster Monitoring and Predication
Disaster Preparedness and Planning
Disaster Repair and Restore
Emergency Response
None

Health

Illness Prevention
Population Health Mgmt. and Consumer Safety
Public Health Monitoring
Health Care Services
Community Health and Safety

Workforce Management

Training and Employment
Labor Rights Management
Worker Safety

Privacy Act System of Records

Privacy Act (when applicable) provide the System of Records Notice (SORN) Name and Number and
the date the SORN published in the Federal Register
Title:
_____________________________________________________________________________
Federal Register Citation:
Volume:
Page Number:
Publication Date:
(mm/dd/yyyy)
200
Number of Respondents: _______

0
Number of Respondents for Small Entity: ______

Affected Public: Choose only one category
Individuals and Households
Private Sector
State, Local, or Tribal Governments
Federal Government
If affected Public is Private Sector check all the following that apply:
Business or other for-profits
Not-for-profits institutions
Farms
Percentage of Respondents Reporting Electronically: ______%
0
Annual IC Time Burden (Hours): _____________
33.33
Annual IC Cost Burden (Dollars): _____________
$801.59
Calculated: Annual Frequency = ___________
times per year (per respondent)
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Calculated: Annual Number of Responses = ________________
a year
200

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Does this IC request a Change in Net Burden?

Yes

No

Annual Response Hours and Cost Burden:
Enter the hours and cost (per response) broken out by reporting, record keeping, and third-party
disclosure.
Hours and Cost Per Response
Time Per
Response
Reporting
10.00 Minutes
Record Keeping
0.00
Third Party
Disclosure
0.00
Total
10.00 Minutes

Hours Per
Response

Annual Hour
Burden

Cost Per
Response

Annual Cost Burden

0.17

0.17

$4.01

$4.01

0.17

0.17

$4.01

$4.01

Explanation of Changes in Hours and Costs (due to revisions or change requests)
Requested
Program
Program
Change Due Change Due
to Potential
Change Due Change Due
to
Violation in
to New
to Agency
Adjustment
PRA
Statute
Discretion
in Agency
Estimate
Annual
Number of
Responses
for this IC
Annual IC
Time
Burden
(Hours)
Annual IC
Cost
Burden
(Dollars )

Previously
Approved

Purpose of information collection (check one)
Application for Benefit

Program Evaluation
General Purpose Statistics
Regulatory/Compliance
Program Planning/Management
Public Health/Emergency Response
Research
Surveillance
Service Delivery/Customer Feedback
Administrative
Audit

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CDC 0.1497 (E), October 2014, CDC Adobe Acrobat 10.1, S508 Electronic Version, October 2014

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