Chronic Disease Self-management Questionnaire

[NCCDPHP] Evaluation of the Chronic Disease Self-Management Program in the US Affiliated Pacific Islands

Documents and Forms

Document Name Document Type
Form 0920-1265 Chronic Disease Self-management Questionnaire Form and Instruction
0920-1265 1265 Att 4(a) CDSMP Questionnaire 1265 Att 4(a) CDSMP Questionnaire.docx Form and Instruction
0920-1265 1265 Att 4(a) CDSMP Questionnaire 1265 Att 4(a) CDSMP Questionnaire.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Chronic Disease Self-management Questionnaire	Agency IC Tracking Number:	0920-1265

Is this a Common Form? No		IC Status: Modified

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	0920-1265	1265 Att 4(a) CDSMP Questionnaire	1265 Att 4(a) CDSMP Questionnaire.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 190	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	380	380
Annual IC Time Burden (Hours)	63	63
Annual IC Cost Burden (Dollars)	0	0

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.