Inpatient hospitalization discharge overdose data form - Health Department Line-level ED and Inpatient Hospitalization Discharge Data - Yearly

[NCIPC] Drug Overdose Surveillance and Epidemiology (DOSE)

Documents and Forms

Document Name Document Type
Form 0920-1268 Inpatient hospitalization discharge overdose data form - Health Department Line-level ED and Inpatient Hospitalization Discharge Data - Yearly Form and Instruction
0920-1268 Inpatient Hospitalization Discharge Overdose Data Form 0920-1268 Att E_ED discharge.xlsx Form and Instruction

Information Collection (IC) Details

IC Title:	Inpatient hospitalization discharge overdose data form - Health Department Line-level ED and Inpatient Hospitalization Discharge Data - Yearly	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	0920-1268	Inpatient Hospitalization Discharge Overdose Data Form	0920-1268 Att E_ED discharge.xlsx	N/A	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 %

	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	35	35
Annual IC Time Burden (Hours)	175	175
Annual IC Cost Burden (Dollars)	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.