OMB control number

[NCCDPHP] Evaluation of the Chronic Disease Self-Management Program in the US Affiliated Pacific Islands

OMB 0920-1265 · HHS/CDC.

OMB 0920-1265

This collection is to evaluate the first implementation of Stanford University's Chronic Disease Self-Management Program in the US Affiliated Pacific Islands. The evaluation will assess program participation satisfaction with the program and participants' overall health and health behaviors before and after the program.The purpose of this evaluation is to look at the fidelity of the program to ensure it is meeting Stanford’s standards for implementation and to know if this program can be effective for people in the USAPIs to better manage their chronic conditions.

The latest form for [NCCDPHP] Evaluation of the Chronic Disease Self-Management Program in the US Affiliated Pacific Islands expires 2026-04-30 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
Form 0920-1265 Chronic Disease Self-management Questionnaire Form and Instruction
Form 0920-1265 Chronic Disease Self-management Workshop Evaluation Form and Instruction
1265 PN.pdf Supplementary Document
1265 Att 8 Privacy Impact Assesment.pdf Supplementary Document
1265 Att 7 IRB Approval.pdf Supplementary Document
1265 Att 6 Participants in Consultation Outside the Agency.docx Supplementary Document
1265 Att 5 CDSMP Evaluation Consent Form.docx Supplementary Document
1265 Att 3 Data Coll & Data Flow Process.docx Supplementary Document
1265 Att 1 Authorizing Legislation.pdf Supplementary Document
Att. 8 Privacy Impact Assesment.pdf Supplementary Document
Att. 7_Institutional Review Board Approval Notification or exemption determination.pdf Supplementary Document
Att. 6 Participants in Consultation Outside the Agency.docx Supplementary Document
Att. 5 CDSMP Evaluation Consent Form.docx Supplementary Document
Att. 3_Data Collection and Data Flow Process.docx Supplementary Document
Att. 2 60 Day Federal Register Notice.pdf Supplementary Document
Att. 1 Authorizing Legislation Section 301(a) of the Public Health Service Act [42.U.S.C. 242K].pdf Supplementary Document
1265 SSB.docx Supporting Statement B
1265 SSA.docx Supporting Statement A
Chronic Disease Self-management Questionnaire Form and Instruction
Chronic Disease Self-management Workshop Evaluation Form and Instruction

All Historical Document Collections

202208-0920-001 Approved without change	Reinstatement without change of a previously approved collection	2023-01-25
201901-0920-012 Approved with change	New collection (Request for a new OMB Control Number)	2019-02-15

OMB Details

Chronic Disease Self-management Workshop Evaluation

Federal Enterprise Architecture: Health - Public Health Monitoring

Form 0920-1265

Att 4 CDSMP Workshop Evaluation

Fillable Fileable

Form and instruction

Review document collections for all forms, instructions, and supporting documents - including paper/printable forms.