Form 1 #17 Email Form and Survey

“Collection of Data from NCI’s Cancer Information Service (CIS) Website

Clients via E-mail Contact Form”

(OMB No. 0925-0046-17; Expiration Date 02/13/2013)

Attachments

17C. New E-mail contact form

17D. Survey questions about the new e-mail contact form

ATTACHMENT 17C

NEW E-MAIL CONTACT FORM

OMB No. 0925-0046-17

Expiration Date 02/28/2013

E

Would you rather speak with one of our Cancer Information Specialists?

1-800-4-CANCER (1-800-422-6237)
8 a.m. to 8 p.m. ET, M-F

nglish/Spanish tabs

E-mail Us

To contact NCI, please fill out this form. The answers that you provide us will help us give you the most useful information.* Personal information will be kept confidential and used only to respond to your question.

*Information provided by this service is not a substitute for personal medical advice. If you need medical advice, please consult your health care provider

E-mail address (if you would like a response):

Enter e-mail address again to confirm:

How would you describe yourself?

• Cancer patient/survivor

• Spouse, relative, or friend of cancer patient

• General public

• Organization

• Health professional

• Scientist/Researcher

• Media

• Student

What is your question about?

• Cancer information (treatment, risk factors, screening)

• Clinical trials

• Complementary and alternative medicine

• Support (financial, emotional, medical supplies)

• Research and funding

• About NCI

• Website questions

• Other

Zip code (if US resident):______________

Country (if outside the US):____________

SUBJECT

(LIMIT 50 CHARACTERS)

MESSAGE

Please limit your message to 2000 characters.

Should your message require a response, you may expect one within 5 business days.

Send Cancel

Privacy Policy on E-mail Messages Sent to the NCI Web Site

Please use the form on this page. Alternatively, you may send an e-mail to cancergovstaff@mail.nih.gov.

Public reporting burden for this collection of information is estimated to average 10 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0046-17). Do not return the completed form to this address.

ATTACHMENT 17D

SURVEY QUESTIONS

OMB No. 0925-0046-17

Expiration Date 02/28/2013

Questions to be located at the end of the draft new E-mail form:

1. Are these questions what you would expect in order to get a complete cancer-related response?

2. Do the questions solicit the most relevant information to in order to receive a satisfying response?

3. What is your preferred way of receiving information?

• Phone

• Email

• Live Chat

• Social media

4. Do you find these questions burdensome or invasive?

5. Please include any additional comments or suggestions.

Public reporting burden for this collection of information is estimated to average 10 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0046-17). Do not return the completed form to this address.

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