CQM Health Department Interview

National Evaluation of the DP18-1815 Cooperative Agreement Program: Category B, Cardiovascular Disease Prevention and Management

Documents and Forms

Document Name Document Type
CQM Health Department Interview Form and Instruction
CQM State Health Department Interview Guide Att 4a. CQM State HD Interview Guide_rev.docx Form and Instruction
CQM State Health Department Interview Guide Att 4a. CQM State HD Interview Guide_rev.docx Form and Instruction

Information Collection (IC) Details

IC Title:	CQM Health Department Interview	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

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	n/a	CQM State Health Department Interview Guide	Att 4a. CQM State HD Interview Guide_rev.docx		No		Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 17	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	17	17
Annual IC Time Burden (Hours)	26	26
Annual IC Cost Burden (Dollars)	1,122	1,122

Documents for IC

Title	Document	Date Uploaded
No associated records found

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