Physician Permission to Contact Potential Survey Respondents

A Study of Primary and Secondary Prevention Behaviors Practiced Among Five-Year Survivors of Colorectal Cancer

Documents and Forms

Document Name Document Type
Physician Permission to Contact Potential Survey Respondents Form
Permission to Contact Potential Participants Attachment D_LIST OF POTENTIAL STUDY PARTICIPANTS.doc Form
Attachment D2_COVER LETTER FOR PHYSICIANS.doc Cover Letter to Physicians IC Document

Information Collection (IC) Details

IC Title:	Physician Permission to Contact Potential Survey Respondents	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	none	Permission to Contact Potential Participants	Attachment D_LIST OF POTENTIAL STUDY PARTICIPANTS.doc		Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title: 09-20-0136 Epidemiologic Studies and Surveillance of Disease Problems	FR Citation: 57 FR 62812

Number of Respondents: 1,950	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,950	1,950
Annual IC Time Burden (Hours)	423	423
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Cover Letter to Physicians	Attachment D2_COVER LETTER FOR PHYSICIANS.doc	04/01/2009

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