Information Collection

Chronic Disease Self-Management Education Program

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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Chronic Disease Self-Management Education Program	Form
Attendance Log Chronic Disease Self-Management Education Program	Form
Program Information Cover Sheet Chronic Disease Self-Management Education Program	Form and Instruction
CDSME Participant Information Survey Chronic Disease Self-Management Education Program	Form and Instruction
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

IC Title:

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.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	N/A	Yes	Yes	Fillable Fileable
Form and Instruction	N/A	Yes	Yes	Fillable Fileable
Form and Instruction	N/A	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 %

table that charts list of burden
	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

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.

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