Well-Integrated Screening and Evaluation for Women Across the Nation (WISEWOMAN) Reporting System

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0612 can be found here:

Documents and Forms

Document Name Document Type
Attachment 3 WISEWOMAN MDE Version 9 0.pdf Instruction
0612 Att 4a Web Portal Login Screenshot Final.png Other-Screenshot
0612 Att 4b Web Portal Submission Screenshot Final.png Other-Screenshot
0920-0612 WISEWOMAN Program MDE Manual Version 9.0 July 2013 WISEWOMAN MDEs.pdf Form and Instruction
Attachment 4 Screen Shots of Portal 09 24 2013.pdf Attachment 4 Screen Shots of Portal IC Document
Exhibits.docx Exhibits 1. Overview of Proposed Improvements IC Document
OMB Change Request Summary 04.06.18.docx Request for Nonmaterial/Non-substantive Change to an OMB Approved IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Well-Integrated Screening and Evaluation for Women Across the Nation (WISEWOMAN) Reporting System	Agency IC Tracking Number:	0920-0612 (20MX)

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			Attachment 3 WISEWOMAN MDE Version 9 0.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	0920-0612	WISEWOMAN Program MDE Manual Version 9.0 July 2013	WISEWOMAN MDEs.pdf	Yes	Yes	Fillable Fileable
Other-Screenshot			0612 Att 4a Web Portal Login Screenshot Final.png	Yes	Yes	Fillable Fileable
Other-Screenshot			0612 Att 4b Web Portal Submission Screenshot Final.png	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 35	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	35	-13	48
Annual IC Time Burden (Hours)	1,680	528	1,152
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Attachment 4 Screen Shots of Portal	Attachment 4 Screen Shots of Portal 09 24 2013.pdf	10/29/2013
Exhibits 1. Overview of Proposed Improvements	Exhibits.docx	04/10/2018
Request for Nonmaterial/Non-substantive Change to an OMB Approved	OMB Change Request Summary 04.06.18.docx	04/10/2018

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