Information Collection

WISEWOMAN Program Minimum Data Elements (MDE)

IC 37802 under ICR 202304-0920-005 · OMB 0920-0612.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0612 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-0612 WISEWOMAN Program Minimum Data Elements (MDE)	Form and Instruction
Att 6 MDE Submission Instructions.pdf	Instruction
Att 6 MDE Submission Instructions.pdf	Instruction
0920-0612 Specifications for WISEWOMAN Minimum Data Elements (MDE wisewoman_MDE_manual_18.3.pdf	Form and Instruction
0920-0612 Specifications for WISEWOMAN Minimum Data Elements (MDE wisewoman_MDE_manual_18.3.pdf	Form and Instruction
Att 4a Web Portal Screenshot.png Screenshot of the WISEWOMAN Web Portal	IC Document
Att 4a Web Portal Screenshot.png Screenshot of the WISEWOMAN Web Portal	IC Document
Att 4b Web Portal Upload Screenshot.png Screenshot (Example) of Uploading MDE Files	IC Document
Att 4b Web Portal Upload Screenshot.png Screenshot (Example) of Uploading MDE Files	IC Document

IC Title:

WISEWOMAN Program Minimum Data Elements (MDE)

Agency IC Tracking Number:

0920-0612-23EG

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

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	0920-0612	Specifications for WISEWOMAN Minimum Data Elements (MDE Manual)	wisewoman_MDE_manual_18.3.pdf		Yes	Yes	Fillable Fileable
Instruction			Att 6 MDE Submission Instructions.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 35

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	70	0	70
Annual IC Time Burden (Hours)	1,750	70	1,680
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Screenshot of the WISEWOMAN Web Portal	Att 4a Web Portal Screenshot.png	08/11/2022
Screenshot (Example) of Uploading MDE Files	Att 4b Web Portal Upload Screenshot.png	08/11/2022

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.