Federal Cervical Cancer Collaborative (FCCC) CERV-Net Evaluation

Voluntary Partner Surveys to Implement Executive Order 12862 in the Health Resources and Services Administration

Documents and Forms

Document Name Document Type
Form 1 Federal Cervical Cancer Collaborative (FCCC) CERV-Net Evaluation Form and Instruction
Form 1 Federal Cervical Cancer Collaborative (FCCC) CERV-Net Evaluation Form and Instruction
1 CERV-Net 3-Month Follow-Up Test 2024-02-13_CERV-Net 3-Month Follow-Up Test.pdf Form and Instruction
1 CERV-Net 3-Month Follow-Up Test 2024-02-13_CERV-Net 3-Month Follow-Up Test.pdf Form and Instruction
2 CERV-Net Post-Test 2024-02-13_CERV-Net Post-Test.pdf Form and Instruction
2 CERV-Net Post-Test 2024-02-13_CERV-Net Post-Test.pdf Form and Instruction
3 CERV-Net Pre-Test 2024-02-13_CERV-Net Pre-Test.pdf Form and Instruction
3 CERV-Net Pre-Test 2024-02-13_CERV-Net Pre-Test.pdf Form and Instruction
2023-02-13_FCCC_OMB-Review_Fast-Track-Memo_V2clean.docx Fast Track Memo_CERV Net IC Document
2023-02-13_FCCC_OMB-Review_Fast-Track-Memo_V2clean.docx Fast Track Memo_CERV Net IC Document

Information Collection (IC) Details

IC Title:	Federal Cervical Cancer Collaborative (FCCC) CERV-Net Evaluation	Agency IC Tracking Number:

IC Status: Unchanged

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	1	CERV-Net 3-Month Follow-Up Test	2024-02-13_CERV-Net 3-Month Follow-Up Test.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	2	CERV-Net Post-Test	2024-02-13_CERV-Net Post-Test.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	3	CERV-Net Pre-Test	2024-02-13_CERV-Net Pre-Test.pdf	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 48	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Previously Approved
Annual Number of Responses for this IC	48	48
Annual IC Time Burden (Hours)	36	36
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Fast Track Memo_CERV Net	2023-02-13_FCCC_OMB-Review_Fast-Track-Memo_V2clean.docx	02/26/2024

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.