Information Collection

SPARCSS Scripts-Screeners

IC 186877 under ICR 200810-0925-003 · OMB 0925-0595.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 SPARCSS Scripts-Screeners	Form and Instruction
1 PCP Script-Screener Attachment 8 PCP Script.doc	Form and Instruction
2 Oncologist Script-Screener Attachment 9 Oncologist Script.doc	Form and Instruction

IC Title:

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
Form and Instruction	1	PCP Script-Screener	Attachment 8 PCP Script.doc		Yes	No	Paper Only
Form and Instruction	2	Oncologist Script-Screener	Attachment 9 Oncologist Script.doc		Yes	No	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 2,033

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	2,033	2,033
Annual IC Time Burden (Hours)	169	169
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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