Information Collection

Community-Level PDMP Outcomes Module

IC 241773 under ICR 202602-0930-002 · OMB 0930-0377.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Community-Level PD Community-Level PDMP Outcomes Module Community-Level PDMP Outcomes Module	Form and Instruction
Community-Level PD Community-Level PDMP Outcomes Module Attachment 3 SPF Rx Community-Level PDMP Outcomes Module_2025_final.docx	Form and Instruction

IC Title:

Agency IC Tracking Number:

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	Community-Level PDMP Outcomes Module				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 26

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
	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	135	25	110
Annual IC Time Burden (Hours)	169	31	138
Annual IC Cost Burden (Dollars)	0	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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