Information Collection

Main Study Survivor Follow-Up Questionnaire - Female

IC 221132 under ICR 201603-0920-013 · OMB 0920-1149.

Documents and Forms

Document Name Document Type
Main Study Survivor Follow-Up Questionnaire - Female Form
Follow-Up Visit Questionnaire for Women Attachment5b-Follow-upQuestionnaire- Female.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Main Study Survivor Follow-Up Questionnaire - Female	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	NA	Follow-Up Visit Questionnaire for Women	Attachment5b-Follow-upQuestionnaire- Female.pdf	NA	No		Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 120	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	480	480
Annual IC Time Burden (Hours)	120	120
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.