Information Collection

Analysis and Use of Core Data Sets

IC 240167 under ICR 202304-0920-006 · OMB 0920-0853.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-0853 Analysis and Use of Core Data Sets	Form and Instruction
Form 0920-0853 PM Reporting Tool MAY2023 Analysis and Use of Core Data Sets	Form and Instruction
Form 0920-0853 ED Visits Reporting Form MAY2023 Analysis and Use of Core Data Sets	Form and Instruction
Form 0920-0853 HD Reporting Form MAY2023 Analysis and Use of Core Data Sets	Form and Instruction
0920-0853 PM Reporting Tool MAY2023 Att5a_PMReportingTool.xlsx	Form and Instruction
0920-0853 PM Reporting Tool MAY2023 Att5a_PMReportingTool.xlsx	Form and Instruction
0920-0853 ED Visits Reporting Form MAY2023 Att6a_AIRS ED Visits Reporting Form.xlsx	Form and Instruction
0920-0853 ED Visits Reporting Form MAY2023 Att6a_AIRS ED Visits Reporting Form.xlsx	Form and Instruction
0920-0853 HD Reporting Form MAY2023 Att7a_AIRS HD Reporting Forms.xlsx	Form and Instruction
0920-0853 HD Reporting Form MAY2023 Att7a_AIRS HD Reporting Forms.xlsx	Form and Instruction
Att8_PM Comparison Table.docx PM Comparison Table	IC Document
Att8_PM Comparison Table.docx PM Comparison Table	IC Document
Att6b_AIRS ED Visits Reporting Example.xlsx ED Visits Reporting Example	IC Document
Att6b_AIRS ED Visits Reporting Example.xlsx ED Visits Reporting Example	IC Document
Att7b_AIRS HD Reporting Example.xlsx HD Reporting Example	IC Document
Att7b_AIRS HD Reporting Example.xlsx HD Reporting Example	IC Document

IC Title:

Agency IC Tracking Number:

0920-0853

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.	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	0920-0853	NA	Yes	Yes	Fillable Fileable
Form and Instruction	0920-0853	NA	Yes	Yes	Fillable Fileable
Form and Instruction	0920-0853	NA	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 90

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	90	90
Annual IC Time Burden (Hours)	105	105
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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

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