Forms and Documents

Document Name	Status
Form 0920-1265 Chronic Disease Self-management Questionnaire Form and Instruction	Modified
Form 0920-1265 Chronic Disease Self-management Workshop Evaluation Form and Instruction	Modified
1265 PN.pdf Supplementary Document	2022-09-07
1265 Att 8 Privacy Impact Assesment.pdf Supplementary Document	2022-09-07
1265 Att 7 IRB Approval.pdf Supplementary Document	2022-09-07
1265 Att 6 Participants in Consultation Outside the Agency.docx Supplementary Document	2022-09-07
1265 Att 5 CDSMP Evaluation Consent Form.docx Supplementary Document	2022-09-07
1265 Att 3 Data Coll & Data Flow Process.docx Supplementary Document	2022-09-07
1265 Att 1 Authorizing Legislation.pdf Supplementary Document	2022-09-07
Att. 8 Privacy Impact Assesment.pdf Supplementary Document	2019-01-31
Att. 7_Institutional Review Board Approval Notification or exemption determination.pdf Supplementary Document	2019-01-31
Att. 6 Participants in Consultation Outside the Agency.docx Supplementary Document	2019-01-31
Att. 5 CDSMP Evaluation Consent Form.docx Supplementary Document	2019-01-31
Att. 3_Data Collection and Data Flow Process.docx Supplementary Document	2019-01-31
Att. 2 60 Day Federal Register Notice.pdf Supplementary Document	2019-01-31
Att. 1 Authorizing Legislation Section 301(a) of the Public Health Service Act [42.U.S.C. 242K].pdf Supplementary Document	2019-01-31
1265 SSB.docx Supporting Statement B	2022-09-07
1265 SSA.docx Supporting Statement A	2023-01-25

IC Document Collections

IC ID	Document Title	Status
234803	Chronic Disease Self-management Questionnaire Form and Instruction	Modified
234802	Chronic Disease Self-management Workshop Evaluation Form and Instruction	Modified

ICR Details

OMB Control No:	ICR Reference No:
Status:	Previous ICR Reference No:
Agency/Subagency:	Agency Tracking No:
Title:
Type of Information Collection:	Common Form ICR:
Type of Review Request:	Date Received in OIRA:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date
Responses	0	0	0
Time Burden (Hours)	0	0	0
Cost Burden (Dollars)	0	0	0

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Abstract:

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Authorizing Statute(s): None

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:

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Federal Register Notices & Comments

Did the Agency receive public comments on this ICR?

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Number of Information Collection (IC) in this ICR: 0

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ICR Summary of Burden

	Total	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	0	0	0	0	0	0
Annual Time Burden (Hours)	0	0	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion:

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion:

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government:

Does this IC contain surveys, censuses, or employ statistical methods?

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.    

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.    

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]?

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]?

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)?

Is this ICR related to the Pandemic Response?

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Common Form ICR: 

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date:

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