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

Forms and Documents

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

IC Document Collections

IC ID	Document Title	Status
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.

	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

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

	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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