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CHIS Cancer Control Module 2011 for Adolescents (CHIS-CCM)
Change Request for California Health Interview Survey Cancer Control Module (CHIS-CCM) 2011 (NCI)
OMB: 0925-0598
IC ID: 187239
OMB.report
HHS/NIH
OMB 0925-0598
ICR 201106-0925-005
IC 187239
( )
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
View Information Collection (IC)
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
Federal Enterprise Architecture Business Reference Module
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
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
2,008
0
0
0
0
2,008
Annual IC Time Burden (Hours)
67
0
0
0
0
67
Annual IC Cost Burden (Dollars)
0
0
0
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.