Information Collection

Million Hearts® Hypertension Control Champion Data Verification Form

IC 206921 under ICR 202601-0920-005 · OMB 0920-0976.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-0976 Million Hearts® Hypertension Control Champion Data Verification Form	Form and Instruction
Form 0920-0976 Million Hearts® Hypertension Control Champion Data Verification Form Million Hearts® Hypertension Control Champion Data Verification Form	Form and Instruction
Form 0920-0976 Data Verification Form Million Hearts® Hypertension Control Champion Data Verification Form	Form
0920-0976 Million Hearts® Hypertension Control Champion Data Verif Attachment 4. Verification Form 0920-0976 (unchanged).docx	Form and Instruction
0920-0976 Million Hearts® Hypertension Control Champion Data Verif Attachment 4. Verification Form 0920-0976 (unchanged).docx	Form and Instruction
0920-0976 Data Verification Form Attachment 4. Data Verification Form 0920-0976 (unchanged).docx	Form
0920-0976 Data Verification Form Attachment 4. Data Verification Form 0920-0976 (unchanged).docx	Form

IC Title:

Million HeartsÂ® Hypertension Control Champion Data Verification Form

Agency IC Tracking Number:

0920-0976

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.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	0920-0976				Yes	Yes	Fillable Fileable
Form	0920-0976				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 40

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: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	40	40
Annual IC Time Burden (Hours)	80	80
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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