Information Collection

Rapid ED Overdose Data Form - Health Departments sharing data from Local Syndromic Data File

IC 275045 under ICR 202504-0920-022 · OMB 0920-1268.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-1268 Rapid ED Overdose Data Form - Health Departments sharing data from Local Syndromic Data File	Form and Instruction
Form 0920-1268 Rapid ED Overdose Death Form Rapid ED Overdose Data Form - Health Departments sharing data from Local Syndromic Data File	Form and Instruction
0920-1268 Rapid ED Overdose Death Form 0920-1268 Att D_Rapid ED ODDF.xlsx	Form and Instruction
0920-1268 Rapid ED Overdose Death Form 0920-1268 Att D_Rapid ED ODDF.xlsx	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

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	0920-1268			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: 3

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
Annual Number of Responses for this IC	36	36
Annual IC Time Burden (Hours)	108	108
Annual IC Cost Burden (Dollars)	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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