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Clinic Staff Instructions: Contact Information and the Consent to be Contacted
Exploratory Research with People Living with Lung Cancer
OMB: 0920-0813
IC ID: 188699
OMB.report
HHS/CDC
OMB 0920-0813
ICR 200904-0920-004
IC 188699
( )
Documents and Forms
Document Name
Document Type
Form 1
Clinic Staff Instructions: Contact Information and the Consent to be Contacted
Form and Instruction
1 Instructions for Clinic Staff & Consent form
Att 5 Instructions for Clinic Staff Revised 01.28.doc
Form and Instruction
3 Scott and White Consent Form
Att 7 Scott and White Consent Form Revised 03 10 09.doc
Form
2 Contact Information and Consent Form
Att 6 Contact Information Form.doc
Form
Att 4 Recruitment Flyer.doc
Recruitment Flyer
IC Document
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Clinic Staff Instructions: Contact Information and the Consent to be Contacted
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
1
Instructions for Clinic Staff & Consent form
Att 5 Instructions for Clinic Staff Revised 01.28.doc
No
No
Paper Only
Form
3
Scott and White Consent Form
Att 7 Scott and White Consent Form Revised 03 10 09.doc
No
No
Paper Only
Form
2
Contact Information and Consent Form
Att 6 Contact Information Form.doc
No
No
Paper Only
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Health Care Services
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
88
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
0 %
Approved
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
88
0
88
0
0
0
Annual IC Time Burden (Hours)
12
0
12
0
0
0
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
Recruitment Flyer
Att 4 Recruitment Flyer.doc
03/20/2009
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.