California Health Interview Survey Cancer Control Module (CHIS-CCM) 2009 (NCI)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 2 Child Weight and Height Materials (CHIS-CCM 2009) (NCI)	Form and Instruction	New	Available
Form 1 CHIS Cancer Control Module 2009 and Demographic Core for Adolescents (CHIS-CCM) (NCI)	Form and Instruction	New	Available
Form 1 CHIS Cancer Control Module 2009 and Demographic Core for Adults (CHIS-CCM) (NCI)	Form and Instruction	New	Available
Attachment6_UCLA_IRB_Approval 24NOV2008.pdf	Supplementary Document	Uploaded 2009-02-23	Available
Certificate of Confidentiality CHIS 2007.pdf	Supplementary Document	Uploaded 2009-02-23	Available
OHSR Determination 2008.pdf	Supplementary Document	Uploaded 2009-02-23	Available
SSB_CHIS_8-11-08.doc	Supporting Statement B	Uploaded 2008-11-03	Available
Attachment4_Memo_from_NIH_Privacy_Act_Officer.doc	Supplementary Document	Uploaded 2008-11-05	Available
Attachment9_Organizations_and_Publications_Using_CHIS_Data.doc	Supplementary Document	Uploaded 2008-11-03	Available
Attachment8_Strata_and_Selection_Probabilities.pdf	Supplementary Document	Uploaded 2008-11-03	Available
Attachment7_CHIS_Data_Security_Policies - COMPLETE.pdf	Supplementary Document	Uploaded 2008-11-03	Available
Attachment6_UCLA_IRB_Approval - PENDING.doc	Supplementary Document	Uploaded 2008-11-03	Available
Attachment3_CHIS_AB_TAC_and_DDRC_Membership.pdf	Supplementary Document	Uploaded 2008-11-03	Available
Attachment2_CHIS_Making_an_Impact.pdf	Supplementary Document	Uploaded 2008-11-03	Available
CHIS 2009 Cover Memo_submission notice.doc	Supplementary Document	Uploaded 2008-11-03	Available
SSA_CHIS_10-21-08.doc	Supporting Statement A	Uploaded 2008-11-03	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
187240	Child Weight and Height Materials (CHIS-CCM 2009) (NCI)	Form and Instruction	New
187239	CHIS Cancer Control Module 2009 and Demographic Core for Adolescents (CHIS-CCM) (NCI)	Form and Instruction	New
187238	CHIS Cancer Control Module 2009 and Demographic Core for Adults (CHIS-CCM) (NCI)	Form and Instruction	New

ICR Details

OMB Control No: 0925-0598	ICR Reference No: 200811-0925-001
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/NIH	Agency Tracking No:
Title: California Health Interview Survey Cancer Control Module (CHIS-CCM) 2009 (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: Approved without change	Conclusion Date: 02/25/2009
	Date Received in OIRA: 11/17/2008
Terms of Clearance: Approved following the upload of supporting documentation on 02/23/2009. All future renewals and updates of this package will be submitted under the same OMB number assigned to this approved package.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	02/28/2011	24 Months From Approved
Responses	26,723	0	0
Time Burden (Hours)	3,437	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The NCI has sponsored four Cancer Control Modules in the California Health Interview Survey (CHIS), and will be sponsoring a fifth to be administered in 2009. CHIS is a telephone survey that collects population-based, standardized health-related data to assess California's progress in meeting Healthy People 2010 objectives for the nation and the state. The purpose of CHIS-CCM is to collect data to allow NCI to examine patterns and trends in cancer screening and follow-up, as well as to study other cancer-related topics such as tobacco control, diet, physical activity, and obesity by collecting data on health- and disease-related topics such as patterns and trends in cancer screening, disease risk factors, disease outcomes, family history of disease, and social factors such as discrimination.. CHIS is designed to be comparable to the National Health Interview Survey (NHIS) data in order to conduct comparative analyses. CHIS also provides enhanced estimates for cancer risk factors and screening among racial/ethnic minority populations.

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Authorizing Statute(s): US Code: 42 USC 285a 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:
	73 FR 49685	08/22/2008
30-day Notice:	Federal Register Citation:	Citation Date:
	73 FR 66651	11/10/2008
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 3

table that charts list of burden

IC Title	Form No.	Form Name
CHIS Cancer Control Module 2009 and Demographic Core for Adults (CHIS-CCM) (NCI)	1	CHIS-CCM Module 2009
CHIS Cancer Control Module 2009 and Demographic Core for Adolescents (CHIS-CCM) (NCI)	1	CHIS-CCM Module 2009
Child Weight and Height Materials (CHIS-CCM 2009) (NCI)	2	Child Weight and Height Materials

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ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	26,723	0	0	26,723	0	0
Annual Time Burden (Hours)	3,437	0	0	3,437	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

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: $1,397,011

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: 11/17/2008

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