Electronic Health Records and Address- Based Sampling Pilots

Cognitive Testing and Pilot Testing for the National Center for Chronic Disease Prevention and Health Promotion

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1291 can be found here:

Documents and Forms

Document Name Document Type
Form 0920-1291 Electronic Health Records and Address- Based Sampling Pilots Form and Instruction
0920-1291 Survey Questionnaire for ABS Online Respondents Attachment 3 Survey Questionnaire for ABS online respondents.docx Form and Instruction
Change request Electronic Health Records and ABS Pilots OMB Control Number 0920-1291 Expiration 3-31-3023 final.docx GenIC Template Information IC Document
Attachment 1- Details of Data Collection for the EHR Project.docx EHR Project Data Collection Information IC Document
Attachment 2 Materials for Invitation to Participate in the ABS Project.docx ABS Project Invitation Materials IC Document

Information Collection (IC) Details

IC Title:	Electronic Health Records and Address- Based Sampling Pilots	Agency IC Tracking Number:	0920-1291-21BY

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	0920-1291	Survey Questionnaire for ABS Online Respondents	Attachment 3 Survey Questionnaire for ABS online respondents.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 5,900	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 50 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	5,900	5,900
Annual IC Time Burden (Hours)	1,950	1,950
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
GenIC Template Information	Change request Electronic Health Records and ABS Pilots OMB Control Number 0920-1291 Expiration 3-31-3023 final.docx	01/20/2021
EHR Project Data Collection Information	Attachment 1- Details of Data Collection for the EHR Project.docx	01/19/2021
ABS Project Invitation Materials	Attachment 2 Materials for Invitation to Participate in the ABS Project.docx	01/19/2021

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