Information Collection

Analysis and Use of Core Data Sets

IC 240167 under ICR 202003-0920-002 · OMB 0920-0853.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0853 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-0853 Analysis and Use of Core Data Sets	Form and Instruction
0920-0853 Performance Measures Reporting Tool Att5a_PMReportingTool.xlsx	Form and Instruction
0920-0853 Emergency Department Visits Reporting Form Att6a_AIRS ED Visits Reporting Form.xlsx	Form and Instruction
0920-0853 Hospital Discharge Reporting Form Att7a_AIRS HD Reporting Forms.xlsx	Form and Instruction
Att5c_Instructions for PM Reporting Tool.docx PM Reporting tool Instructions	IC Document
Att6b_AIRS ED Visits Reporting Example.xlsx ED Reporting example	IC Document
Att7b_AIRS HD Reporting Example.xlsx HD reporting example	IC Document
Att8_PM Comparison Table.docx PM Comparison Table	IC Document

IC Title:

Analysis and Use of Core Data Sets

Agency IC Tracking Number:

0920-0853

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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	0920-0853	Performance Measures Reporting Tool	Att5a_PMReportingTool.xlsx	Yes	Yes	Fillable Fileable
Form and Instruction	0920-0853	Emergency Department Visits Reporting Form	Att6a_AIRS ED Visits Reporting Form.xlsx	Yes	Yes	Fillable Fileable
Form and Instruction	0920-0853	Hospital Discharge Reporting Form	Att7a_AIRS HD Reporting Forms.xlsx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 90

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

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	90	90
Annual IC Time Burden (Hours)	105	105
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
PM Reporting tool Instructions	Att5c_Instructions for PM Reporting Tool.docx	03/02/2020
ED Reporting example	Att6b_AIRS ED Visits Reporting Example.xlsx	03/02/2020
HD reporting example	Att7b_AIRS HD Reporting Example.xlsx	03/02/2020
PM Comparison Table	Att8_PM Comparison Table.docx	03/02/2020

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