Disability and Health Data System Evaluaton Survey

CDC/ATSDR Formative Research and Tool Development

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1154 can be found here:

Documents and Forms

Document Name Document Type
Form 0920-1154 Disability and Health Data System Evaluaton Survey Form and Instruction
0920-1154 Disability and Halth Data System Evaulation Survey Attachment 1_DHDS 2018 Evaluation Survey.docx Form and Instruction
GenICRequest_DHDS 2018 Evaluation Survey_03282018.tfs4.docx Request for Approval IC Document

Information Collection (IC) Details

IC Title:	Disability and Health Data System Evaluaton Survey	Agency IC Tracking Number:	0920-1154 (18WS)

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	0920-1154	Disability and Halth Data System Evaulation Survey	Attachment 1_DHDS 2018 Evaluation Survey.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 2,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	2,000	2,000
Annual IC Time Burden (Hours)	167	167
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Request for Approval	GenICRequest_DHDS 2018 Evaluation Survey_03282018.tfs4.docx	03/29/2018

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