Information Collection

Annual Report, 2020-2023

IC 241383 under ICR 202003-0920-009 · OMB 0920-0841.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0841 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Annual Report, 2020-2023	Form and Instruction
Annual Report data elements and screens 0841 Att 4a Revised MIS Data Elements FINAL.docx	Form and Instruction
(New) Leadership tab data elements and screen shots 0841 Att 4b Summary of Proposed MIS Changes FINAL.docx	Form and Instruction
Action Plan data elements and screen shots 0841 Att 4h CDMIS Action Plan Tab User Guide FINAL.pdf	Form and Instruction
0841 Att 4c CDMIS Data Entry Screenshot FINAL.JPG Example data entry screenshot	IC Document
0841 Att 4d CDMIS Login Page Screenshot FINAL.JPG Secure log-in screen shot	IC Document

IC Title:

Annual Report, 2020-2023

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

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	N/A	Annual Report data elements and screens	0841 Att 4a Revised MIS Data Elements FINAL.docx	Yes	Yes	Fillable Fileable
Form and Instruction	N/A	(New) Leadership tab data elements and screen shots	0841 Att 4b Summary of Proposed MIS Changes FINAL.docx	Yes	Yes	Fillable Fileable
Form and Instruction	N/A	Action Plan data elements and screen shots	0841 Att 4h CDMIS Action Plan Tab User Guide FINAL.pdf	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 66

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	66	66
Annual IC Time Burden (Hours)	66	66
Annual IC Cost Burden (Dollars)	2,581	2,581

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Example data entry screenshot	0841 Att 4c CDMIS Data Entry Screenshot FINAL.JPG	04/16/2020
Secure log-in screen shot	0841 Att 4d CDMIS Login Page Screenshot FINAL.JPG	04/16/2020

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