Information Collection

Electronic Health Records and Address- Based Sampling Pilots

IC 245344 under ICR 202009-0920-019 · OMB 0920-1291.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
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

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:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.