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DSMES Partner Site-Level Rapid Evaluation Nomination
National Evaluation of the DP18-1815 Cooperative Agreement Program: Category A, Diabetes Management and Type 2 Diabetes Prevention
OMB: 0920-1312
IC ID: 241401
OMB.report
HHS/CDC
OMB 0920-1312
ICR 201910-0920-009
IC 241401
( )
Documents and Forms
Document Name
Document Type
DSMES Partner Site-Level Rapid Evaluation Nomination
Form and Instruction
Att 4a. DSMES Site Nom Form.docx
Other-WORD view of screen shot conte
DSMES Site-Level Rapid Evaluation - Site Nomination Form
Att 4aa. DSMES Nom Form Screenshots.pdf
Form and Instruction
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
DSMES Partner Site-Level Rapid Evaluation Nomination
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
n/a
DSMES Site-Level Rapid Evaluation - Site Nomination Form (screen shots)
Att 4aa. DSMES Nom Form Screenshots.pdf
Yes
Yes
Fillable Fileable
Other-WORD view of screen shot content
Att 4a. DSMES Site Nom Form.docx
No
Paper Only
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Public Health Monitoring
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
17
Number of Respondents for Small Entity:
0
Affected Public:
State, Local, and Tribal Governments
Percentage of Respondents Reporting Electronically:
100 %
Approved
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
17
0
17
0
0
0
Annual IC Time Burden (Hours)
9
0
9
0
0
0
Annual IC Cost Burden (Dollars)
374
0
374
0
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.