Screening Eligibility Assessment (SEA) Form

Health Care Systems for Tracking Colorectal Cancer Screening Tests

Documents and Forms

Document Name Document Type
Form Form #2 Screening Eligibility Assessment (SEA) Form Form and Instruction
Form #2 Screening Eligibility Assessment (SEA) Form Attachment C1 -- A Screening Eligibility (SEA) Form.doc Form and Instruction
Attachment D1 -- Screening Elibility Letter.doc Attachment D1 -- Screening Elibility Letter IC Document

Information Collection (IC) Details

IC Title:	Screening Eligibility Assessment (SEA) Form	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
Form and Instruction	Form #2	Screening Eligibility Assessment (SEA) Form	Attachment C1 -- A Screening Eligibility (SEA) Form.doc		No	No	Paper Only

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 7,500	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	7,500	7,500
Annual IC Time Burden (Hours)	1,250	1,250
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Attachment D1 -- Screening Elibility Letter	Attachment D1 -- Screening Elibility Letter.doc	07/25/2008

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