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Agenda
Reg Review
ICR
View Information Collection (IC)
View Information Collection (IC)
IC Title:
Well-Integrated Screening and Evaluation for Women Across the Nation (WISEWOMAN) Reporting System
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
Instruction
Attachment 3 WISEWOMAN MDE Version 9 0.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
0920-0612
WISEWOMAN Program MDE Manual Version 9.0 July 2013
WISEWOMAN MDEs.pdf
Yes
Yes
Fillable Fileable
Other-Screenshot
0612 Att 4a Web Portal Login Screenshot Final.png
Yes
Yes
Fillable Fileable
Other-Screenshot
0612 Att 4b Web Portal Submission Screenshot Final.png
Yes
Yes
Fillable Fileable
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:
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 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
70
0
35
0
0
35
Annual IC Time Burden (Hours)
1,680
0
0
0
0
1,680
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
Exhibits 1. Overview of Proposed Improvements
Exhibits.docx
04/10/2018
Request for Nonmaterial/Non-substantive Change to an OMB Approved
OMB Change Request Summary 04.06.18.docx
04/10/2018
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.