Information Collection

Clinical Outcomes Data

IC 275885 under ICR 202506-0935-002 · OMB unassigned.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 5 Clinical Outcomes Data	Form
Form 5 Clinical Outcomes Data Template Clinical Outcomes Data	Form
Attachment J - Submission Guide for Clinical Outcomes Data Collection.docx	Instruction
Attachment J - Submission Guide for Clinical Outcomes Data Collection.docx	Instruction
5 Clinical Outcomes Data Template Attachment I - Clinical Outcomes Data Template.docx	Form
5 Clinical Outcomes Data Template Attachment I - Clinical Outcomes Data Template.docx	Form

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	5				Yes	Yes	Fillable Fileable
Instruction					Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 23

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	92	92
Annual IC Time Burden (Hours)	115	115
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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