Information Collection

WISEWOMAN Program Minimum Data Elements (MDE)

IC 37802 under ICR 202502-0920-014 · OMB 0920-0612.

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
Form 0920-0612 WISEWOMAN Program MDE Manual Edition 18.3R WISEWOMAN Program Minimum Data Elements (MDE)	Form and Instruction
Form 0920-0621 WISEWOMAN-MDE_Manual_23.1 WISEWOMAN Program Minimum Data Elements (MDE)	Form and Instruction
Att 6 MDE Submission Instructions.pdf	Instruction
Att 6 MDE Submission Instructions.pdf	Instruction
Attachment 7a Copy of MDE Submission Instructions.pdf	Instruction
Attachment 7a Copy of MDE Submission Instructions.pdf	Instruction
0920-0612 WISEWOMAN Program MDE Manual Edition 18.3R wisewoman_MDE_manual_18.3.pdf	Form and Instruction
0920-0612 WISEWOMAN Program MDE Manual Edition 18.3R wisewoman_MDE_manual_18.3.pdf	Form and Instruction
0920-0621 WISEWOMAN-MDE_Manual_23.1 WISEWOMAN-MDE_Manual_23.1.pdf	Form and Instruction
0920-0621 WISEWOMAN-MDE_Manual_23.1 WISEWOMAN-MDE_Manual_23.1.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:

Agency IC Tracking Number:

0920-0612-23HT

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.	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	0920-0612		Yes	Yes	Fillable Fileable
Instruction			Yes	Yes	Fillable Fileable
Form and Instruction	0920-0621	N/A	Yes	Yes	Fillable Fileable
Instruction		N/A	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 40

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	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	80	80
Annual IC Time Burden (Hours)	2,000	2,000
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Screenshot of the WISEWOMAN Web Portal		08/11/2022
Screenshot (Example) of Uploading MDE Files		08/11/2022

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

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