E-mail Intake form

Collection of Customer Service, Demographic and Smoking/Tobacco Use Information from NCI's Contact Center, Cancer Information Service (CIS) Clients (NCI)

Documents and Forms

Document Name Document Type
Form 6 E-mail Intake form Form
6 Email Intake Form on Cancer.gov Appendix 2 Email Intake Form on Cancer.gov.docx Form
6 Email Intake Form on Cancer.gov Appendix 2 Email Intake Form on Cancer.gov.docx Form

Information Collection (IC) Details

IC Title:	E-mail Intake form	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	6	Email Intake Form on Cancer.gov	Appendix 2 Email Intake Form on Cancer.gov.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: 09-25-0156, “Records of Participants in Programs and Respondents in Surveys Used to Evaluate Programs of the Public Health Service	FR Citation: 67 FR 67042

Number of Respondents: 8,796	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	8,796	7,794	1,002
Annual IC Time Burden (Hours)	1,466	1,299	167
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.