EHR Data

The Centers for Disease Control and Prevention (CDC) Study on Disparities in Distress Screening among Lung and Ovarian Cancer Survivors

Documents and Forms

Document Name Document Type
Form 0920-19MM EHR Data Form and Instruction
0920-19MM EHR data collection tool Att 4- EHR data collection tool DS.docx Form and Instruction

Information Collection (IC) Details

IC Title:	EHR Data	Agency IC Tracking Number:	0920-19MM

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	0920-19MM	EHR data collection tool	Att 4- EHR data collection tool DS.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 50	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 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	50	50
Annual IC Time Burden (Hours)	375	375
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.