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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
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

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:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.