ED Discharge Overdose data (annual reporting)

[NCIPC] Drug Overdose Surveillance and Epidemiology (DOSE)

Documents and Forms

Document Name Document Type
Form 0920-1268 ED Discharge Overdose data (annual reporting) Form and Instruction
0920-1268 ED Annual Discharge Overdose Data Form Att E_template DD OD2A-S (1).xlsx Form and Instruction
0920-1268 ED Annual Discharge Overdose Data Form Att E_template DD OD2A-S (1).xlsx Form and Instruction

Information Collection (IC) Details

IC Title:	ED Discharge Overdose data (annual reporting)	Agency IC Tracking Number:	0920-1268-23DH

Is this a Common Form? No		IC Status: Modified

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	0920-1268	ED Annual Discharge Overdose Data Form	Att E_template DD OD2A-S (1).xlsx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 35	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 Agency Discretion	Previously Approved
Annual Number of Responses for this IC	35	12	23
Annual IC Time Burden (Hours)	88	19	69
Annual IC Cost Burden (Dollars)	3,136	1,075	2,061

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.