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Physician Permission to Contact Potential Survey Respondents
A Study of Primary and Secondary Prevention Behaviors Practiced Among Five-Year Survivors of Colorectal Cancer
OMB: 0920-0815
IC ID: 188830
OMB.report
HHS/CDC
OMB 0920-0815
ICR 200904-0920-010
IC 188830
( )
Documents and Forms
Document Name
Document Type
Physician Permission to Contact Potential Survey Respondents
Form
Permission to Contact Potential Participants
Attachment D_LIST OF POTENTIAL STUDY PARTICIPANTS.doc
Form
Attachment D2_COVER LETTER FOR PHYSICIANS.doc
Cover Letter to Physicians
IC Document
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Physician Permission to Contact Potential Survey Respondents
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
Permission to Contact Potential Participants
Attachment D_LIST OF POTENTIAL STUDY PARTICIPANTS.doc
Yes
No
Fillable Fileable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Public Health Monitoring
Privacy Act System of Records
Title:
09-20-0136 Epidemiologic Studies and Surveillance of Disease Problems
FR Citation:
57 FR 62812
Number of Respondents:
1,950
Number of Respondents for Small Entity:
0
Affected Public:
Private Sector
Private Sector:
Businesses or other for-profits
Percentage of Respondents Reporting Electronically:
100 %
Approved
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
1,950
0
1,950
0
0
0
Annual IC Time Burden (Hours)
423
0
423
0
0
0
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
Cover Letter to Physicians
Attachment D2_COVER LETTER FOR PHYSICIANS.doc
04/01/2009
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.