Cancer Care for Uninsured Individuals: A Feasibility Study (NCI)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 2 Data Collection Form for Physicians	Form	New	Repair queued
Form 1 Telephone Survey on Insurance Status for PLCO Participants	Form and Instruction	New	Repair queued
SSB_Cancer Care.doc	Supporting Statement B	Uploaded 2008-02-20	Repair queued
Cover memo.doc	Supplementary Document	Uploaded 2008-02-20	Repair queued
Attach 10_Privacy Act Memo.doc	Supplementary Document	Uploaded 2008-02-20	Repair queued
Attach 9b_IRB amendment 20070517.pdf	Supplementary Document	Uploaded 2008-02-20	Repair queued
Attach 9a_IRB approval jan 17 2007 2.pdf	Supplementary Document	Uploaded 2008-02-20	Repair queued
Attach 8_HIPAA memo.doc	Supplementary Document	Uploaded 2008-02-20	Repair queued
Attach 7_HIPAA form.doc	Supplementary Document	Uploaded 2008-02-20	Repair queued
Attach 6_Medical records permission.doc	Supplementary Document	Uploaded 2008-02-20	Repair queued
Attach 5_PLCO consent form.doc	Supplementary Document	Uploaded 2008-02-20	Repair queued
Attach 4_Telephone script_rev.doc	Supplementary Document	Uploaded 2008-02-20	Repair queued
Attach 3_Letter to participants_rev.doc	Supplementary Document	Uploaded 2008-02-20	Repair queued
Attach 2_Data Collection Form for Physicians.doc	Supplementary Document	Uploaded 2008-02-20	Repair queued
Attach 1_Letter to doctor final_rev.doc	Supplementary Document	Uploaded 2008-02-20	Repair queued
Attach 1_Letter to doctor final_rev.doc	Supplementary Document	Uploaded 2008-02-20	Repair queued
Attach 3_Letter to participants_rev.doc	Supplementary Document	Uploaded 2008-02-20	Repair queued
SSA_2-08-08.doc	Supporting Statement A	Uploaded 2008-02-20	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
184189	Data Collection Form for Physicians	Form	New
184188	Telephone Survey on Insurance Status for PLCO Participants	Form and Instruction	New

ICR Details

OMB Control No:	ICR Reference No: 200803-0925-004
Status: Historical Inactive	Previous ICR Reference No:
Agency/Subagency: HHS/NIH	Agency Tracking No:
Title: Cancer Care for Uninsured Individuals: A Feasibility Study (NCI)
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Withdrawn	Conclusion Date: 07/01/2008
	Date Received in OIRA: 03/20/2008
Terms of Clearance: NIH is considering whether to submit a new package with a more robust design. If the study is submitted again, OMB would waive the 60 day Federal Register notice.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date		36 Months From Approved
Responses	0	0	0
Time Burden (Hours)	0	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The purpose of this information collection is to conduct a pilot study to assess the feasibility of obtaining health insurance information for participants of the Prostate, Lung, Colon and Ovarian (PLCO) Cancer Screening Trial (OMB#: 0925-0407). The information will be used to develop a study to compare the health care utilization of insured and uninsured PLCO participants. Such study will help understand the results of the PLCO Cancer Screening Trial and other screening trials currently being sponsored by the NIH as their success is conditional on participants' access to care following a recommendation for follow-up. Information will be requested from 50 physicians and 150 Alabama PLCO participants who had a positive cancer screening test and/or were diagnosed with cancer who did not receive follow-up care.

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Authorizing Statute(s): US Code: 42 USC 412 (285a-1) Name of Law: Public Health Service Act
   US Code: 42 USC 412 (285a-2) Name of Law: Public Health Service Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	72 FR 72741	12/21/2007
30-day Notice:	Federal Register Citation:	Citation Date:
	73 FR 11122	02/29/2008
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 2

table that charts list of burden

IC Title	Form No.	Form Name
Telephone Survey on Insurance Status for PLCO Participants	1	Telephone Survey
Data Collection Form for Physicians	2	Data Collection for Physicians

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Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: This is a new collection of information.

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Annual Cost to Federal Government: $0

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 03/20/2008

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