Participant Posttest (Adult intervention participants)

COMMUNITY EVALUATION OF THE NATIONAL DIABETES EDUCATION PROGRAMS DIABETES HEALTHSENSE WEBSITE

Documents and Forms

Document Name Document Type
Form 2 Participant Posttest (Adult intervention participants) Form and Instruction
2 Participant Posttest 3B - NDEP DHS Particpant Posttest_121913_OMB30.pdf Form and Instruction
3B - NDEP DHS Participant Posttest_110613_OMB30.docx 3B - NDEP DHS Participant Posttest_110613_OMB30 IC Document

Information Collection (IC) Details

IC Title:	Participant Posttest (Adult intervention participants)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	2	Participant Posttest	3B - NDEP DHS Particpant Posttest_121913_OMB30.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 150	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	150	150
Annual IC Time Burden (Hours)	50	50
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
3B - NDEP DHS Participant Posttest_110613_OMB30	3B - NDEP DHS Participant Posttest_110613_OMB30.docx	01/13/2014

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