Information Collection

Screener for survivors from advocacy groups

IC 220162 under ICR 201602-0920-011 · OMB 0920-1123.

Documents and Forms

Document Name Document Type
Screener for survivors from advocacy groups Form
Breast Cancer in Young Women screener Attachment 4-scr - Intro_Screening for Web-bsed Survey English.pdf Form
Breast Cancer in Young Women screener - Spanish Attachment 4s-scr - Intro_Screening for Web-bsed Survey Spanish.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Screener for survivors from advocacy groups	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	none	Breast Cancer in Young Women screener	Attachment 4-scr - Intro_Screening for Web-bsed Survey English.pdf		Yes	Yes	Fillable Fileable
Form	none	Breast Cancer in Young Women screener - Spanish	Attachment 4s-scr - Intro_Screening for Web-bsed Survey Spanish.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 25	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	25	25
Annual IC Time Burden (Hours)	1	1
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.