Cx3 Study - Patient Enrollment Form

CDC Cervical Cancer Study (CX3)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0814 can be found here:

Documents and Forms

Document Name Document Type
Att E1d_Patient enrollment form_0209.doc Other-WORD

Information Collection (IC) Details

IC Title:	Cx3 Study - Patient Enrollment Form	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
Other-WORD			Att E1d_Patient enrollment form_0209.doc		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title: 09-20-0136 Epidemiologic Studies and Surveillance of Disease Problems	FR Citation: 57 FR 252

Number of Respondents: 2,667	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	2,667	2,667
Annual IC Time Burden (Hours)	222	222
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.