OMB
.report
Search
Worksheets for Scheduling Site Visit Interviews (Private Sector)
Case Studies to Explore Interventions to Support, Build, and Provide Legacy Awareness for Young Breast Cancer Survivors
OMB: 0920-1012
IC ID: 210396
OMB.report
HHS/CDC
OMB 0920-1012
ICR 201402-0920-013
IC 210396
( )
Documents and Forms
Document Name
Document Type
Att 6f_Worksheet for Scheduling Interviews_12.17.13.docx
Other-WORD
Att 6e_Worksheet for Identifying Interviewees_12.17.13.docx
Other-WORD
Att 6d_Site Visit Preparation Call_02.10.2014.docx
Att 6d_Site Visit Preparation Call_02
IC Document
Att 7a_Document Review Form_9.11.13.docx
Att 7a_Document Review Form_9
IC Document
Att 7b_Observation Form_9.11.13.docx
Att 7b_Observation Form_9
IC Document
Att 8_Interview Guide Matrix_12.18.13.docx
Att 8_Interview Guide Matrix_12
IC Document
Att 9_Informed Consent_12.18.13.docx
Att 9_Informed Consent_12
IC Document
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Worksheets for Scheduling Site Visit Interviews (Private Sector)
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
Other-WORD
Att 6f_Worksheet for Scheduling Interviews_12.17.13.docx
Yes
Yes
Fillable Printable
Other-WORD
Att 6e_Worksheet for Identifying Interviewees_12.17.13.docx
No
No
Fillable Fileable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Immunization Management
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
7
Number of Respondents for Small Entity:
0
Affected Public:
Private Sector
Private Sector:
Not-for-profit institutions
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
7
0
7
0
0
0
Annual IC Time Burden (Hours)
14
0
14
0
0
0
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
Att 6d_Site Visit Preparation Call_02
Att 6d_Site Visit Preparation Call_02.10.2014.docx
02/10/2014
Att 7a_Document Review Form_9
Att 7a_Document Review Form_9.11.13.docx
02/10/2014
Att 7b_Observation Form_9
Att 7b_Observation Form_9.11.13.docx
02/10/2014
Att 8_Interview Guide Matrix_12
Att 8_Interview Guide Matrix_12.18.13.docx
02/10/2014
Att 9_Informed Consent_12
Att 9_Informed Consent_12.18.13.docx
02/10/2014
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.