Chronic Disease Self-Management Education Program

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0985-0036 can be found here:

Documents and Forms

Document Name Document Type
Form 1 Chronic Disease Self-Management Education Program Form and Instruction
1 Program Information Cover Sheet Program-Info-Cover-Sheet.pdf Form and Instruction
2 Participant Information Survey Participant-Info-Survey.pdf Form and Instruction
3 Attendance Log Attendance-Log.pdf Form and Instruction
4 Host ImplementationInfoForm Host-Implementation InfoForm.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Chronic Disease Self-Management Education Program	Agency IC Tracking Number:

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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	1	Program Information Cover Sheet	Program-Info-Cover-Sheet.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	2	Participant Information Survey	Participant-Info-Survey.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	3	Attendance Log	Attendance-Log.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	4	Host ImplementationInfoForm	Host-Implementation InfoForm.pdf	Yes	Yes	Fillable Fileable

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 4,632	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	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	4,632	-28,056	4,632	28,056
Annual IC Time Burden (Hours)	586	-3,791	827	3,550
Annual IC Cost Burden (Dollars)	0	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.