Information Collection

Community-Level PDMP Outcomes Module

IC 241773 under ICR 202211-0930-003 · OMB 0930-0377.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0930-0377 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Community-Level PD Community-Level PDMP Outcomes Module	Form and Instruction
Community-Level PD Community-Level PDMP Outcomes Module Attachment 3 SPF-Rx Community-Level PDMP Outcomes Module CLEAN - 13July2022.docx	Form and Instruction
Community-Level PD Community-Level PDMP Outcomes Module Attachment 3 SPF-Rx Community-Level PDMP Outcomes Module CLEAN - 13July2022.docx	Form and Instruction

IC Title:

Community-Level PDMP Outcomes Module

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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	Community-Level PDMP Outcomes Module	Community-Level PDMP Outcomes Module	Attachment 3 SPF-Rx Community-Level PDMP Outcomes Module CLEAN - 13July2022.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 21

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	110	-13	123
Annual IC Time Burden (Hours)	138	-210	348
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
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.