View Information Collection (IC)

View Information Collection (IC)

View Information Collection (IC)

IC Title:	Combined MDE for Screening and Assessment MDE and Lifestyle Program MDE	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

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	0920-0612	Attachment 3a WISEWOMAN MDE Version 9	Attachment 3a WISEWOMAN MDE Version 9 00_08 08 2013.docx		Yes	Yes	Fillable Fileable
Form and Instruction	0920-0612	Attachment 3b Summary of MDE Changes	Attachment 3b Summary of MDE Changes 091913IV.docx		Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 21	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	42	0	0	0	0	42
Annual IC Time Burden (Hours)	1,008	0	0	336	0	672
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
Attachment 4 Screen Shots of Portal	Attachment 4 Screen Shots of Portal 09 24 2013.pdf	10/29/2013

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