CHIS Cancer Control Module 2011 for Adolescents (CHIS-CCM)

Change Request for California Health Interview Survey Cancer Control Module (CHIS-CCM) 2011 (NCI)

Documents and Forms

Document Name Document Type
Form 1 CHIS Cancer Control Module 2011 for Adolescents (CHIS-CCM) Form and Instruction
1 CHIS-CCM 2011 Attach 1 CHIS2011-CCM_1-10-2011_v 6.docx Form and Instruction

Information Collection (IC) Details

IC Title:	CHIS Cancer Control Module 2011 for Adolescents (CHIS-CCM)	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 and Instruction	1	CHIS-CCM 2011	Attach 1 CHIS2011-CCM_1-10-2011_v 6.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title: SORN No. 09-25-0200 "Clinical, Basic and Population-based Research Studies of the National Institutes of Health (NIH), HHS/NIH/OD"	FR Citation: 67 FR 60776

Number of Respondents: 1,106	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	2,008	2,008
Annual IC Time Burden (Hours)	67	67
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.