Information Collection

Chronic Disease Self-Management Education Program

IC 206269 under ICR 202211-0985-001 · OMB 0985-0036.

Documents and Forms

Document Name Document Type
Chronic Disease Self-Management Education Program Form
Attendance Log 0036 Attendance Log.pdf Form
Attendance Log 0036 Attendance Log.pdf Form
Program Information Cover Sheet 0036 Program Information_Cover Sheet_ 2022.pdf Form and Instruction
Program Information Cover Sheet 0036 Program Information_Cover Sheet_ 2022.pdf Form and Instruction
CDSME Participant Information Survey 0036 CDSME-Participant-Information Survey- 2022.pdf Form and Instruction
CDSME Participant Information Survey 0036 CDSME-Participant-Information Survey- 2022.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Chronic Disease Self-Management Education Program	Agency IC Tracking Number:

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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	N/A	Attendance Log	0036 Attendance Log.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	N/A	Program Information Cover Sheet	0036 Program Information_Cover Sheet_ 2022.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	N/A	CDSME Participant Information Survey	0036 CDSME-Participant-Information Survey- 2022.pdf	Yes	Yes	Fillable Fileable

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 14,750	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	14,750	-165	14,915
Annual IC Time Burden (Hours)	3,534	159	3,375
Annual IC Cost Burden (Dollars)	0	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.