Information Collection

Telephone Survey on Insurance Status for PLCO Participants

IC 184188 under ICR 200803-0925-004 · OMB unassigned.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Telephone Survey on Insurance Status for PLCO Participants	Form and Instruction
1 Telephone Survey Attach 4_Telephone script_rev.doc	Form and Instruction
Attach 3_Letter to participants_rev.doc Attach 3_Letter to participants_rev	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? Yes

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
Form and Instruction	1	Telephone Survey	Attach 4_Telephone script_rev.doc		No	No	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 150

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	150	150
Annual IC Time Burden (Hours)	13	13
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attach 3_Letter to participants_rev	Attach 3_Letter to participants_rev.doc	02/20/2008

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