Evaluation Questionnaire

interactive Comprehensive Lifestyle Interview by Computer (iCLIC) Study (NCI)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0594 can be found here:

Documents and Forms

Document Name Document Type
Form 9 Evaluation Questionnaire Form
9 Evaluation Questionnaire Att 9_EvaluationQuestionnaire.doc Form

Information Collection (IC) Details

IC Title:	Evaluation Questionnaire	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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	9	Evaluation Questionnaire	Att 9_EvaluationQuestionnaire.doc		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,716	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	1,716	681	1,035
Annual IC Time Burden (Hours)	29	12	17
Annual IC Cost Burden (Dollars)	0	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.