Information Collection

Analysis and Use of Core Data Sets

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

Documents and Forms

Document Name Document Type
Form 0920-0853 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

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Analysis and Use of Core Data Sets	Agency IC Tracking Number:	0920-0853

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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	0920-0853	PM Reporting Tool MAY2023	Att5a_PMReportingTool.xlsx	NA	Yes	Yes	Fillable Fileable
Form and Instruction	0920-0853	ED Visits Reporting Form MAY2023	Att6a_AIRS ED Visits Reporting Form.xlsx	NA	Yes	Yes	Fillable Fileable
Form and Instruction	0920-0853	HD Reporting Form MAY2023	Att7a_AIRS HD Reporting Forms.xlsx	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 %

	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

Title	Document	Date Uploaded
PM Comparison Table	Att8_PM Comparison Table.docx	05/16/2023
ED Visits Reporting Example	Att6b_AIRS ED Visits Reporting Example.xlsx	05/16/2023
HD Reporting Example	Att7b_AIRS HD Reporting Example.xlsx	05/16/2023

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