Information Collection

Questionnaires, Scripts, and Letters

IC 182207 under ICR 200710-0925-001 · OMB 0925-0583.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0583 can be found here:

Documents and Forms

Document Name Document Type
Attachment 6 Instructions Letters Scripts.pdf Instruction
1 All Questionaires Instruments To OMB 09-24-07 -2.pdf Form and Instruction
Attachment 5 Klabunde et al.pdf Attachment 5 Klabunde et al IC Document
Attachment 3a Documentation of IRB Approval.pdf Attachment 3a Documentation of IRB Approval IC Document
Attachment 3b SmithA_NCI_Exempt_3827_CY2007.pdf Attachment 3b SmithA_NCI_Exempt_3827_CY2007 IC Document
Attachment 2 Privacy Act Statement.pdf Attachment 2 Privacy Act Statement IC Document
FINALLetter to Physicians for EB Provider Survey RBB 09-14-07.doc FINALLetter to Physicians for EB Provider Survey RBB 09-14-07 IC Document
Letter to Admin for AdminSurvey 09-14-07.doc Letter to Admin for AdminSurvey 09-14-07 IC Document
FAQs for EBalance5 09-07.doc FAQs for EBalance5 09-07 IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Questionnaires, Scripts, and Letters	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
Instruction			Attachment 6 Instructions Letters Scripts.pdf		Yes	Yes	Paper Only
Form and Instruction	1	All Questionaires	Instruments To OMB 09-24-07 -2.pdf		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 4,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	4,000	4,000
Annual IC Time Burden (Hours)	1,320	1,320
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Attachment 5 Klabunde et al	Attachment 5 Klabunde et al.pdf	09/05/2007
Attachment 3a Documentation of IRB Approval	Attachment 3a Documentation of IRB Approval.pdf	09/05/2007
Attachment 3b SmithA_NCI_Exempt_3827_CY2007	Attachment 3b SmithA_NCI_Exempt_3827_CY2007.pdf	09/05/2007
Attachment 2 Privacy Act Statement	Attachment 2 Privacy Act Statement.pdf	09/05/2007
FINALLetter to Physicians for EB Provider Survey RBB 09-14-07	FINALLetter to Physicians for EB Provider Survey RBB 09-14-07.doc	09/24/2007
Letter to Admin for AdminSurvey 09-14-07	Letter to Admin for AdminSurvey 09-14-07.doc	09/24/2007
FAQs for EBalance5 09-07	FAQs for EBalance5 09-07.doc	09/24/2007

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