Information Collection

Survey of Health Behaviors for Five-Year Survivors of Colorectal Cancer

IC 188831 under ICR 200904-0920-010 · OMB 0920-0815.

Documents and Forms

Document Name Document Type
Survey of Health Behaviors for Five-Year Survivors of Colorectal Cancer Form
Survey of Health Behaviors Attachment E_Survey of Health Behaviors_031809.pdf Form
Attachment E1_ADVANCE LETTER FOR RESPONDENTS.doc Advance Letter for Respondents IC Document
Attachment E2_CCR Brochure.pdf California Cancer Registry Brochure IC Document
Attachment E3_COVER LETTER FOR SURVEY PACKET.doc Cover Letter for Survey Packet IC Document
Attachment E4_PARTICIPANT CONSENT FORM.doc Consent Form IC Document
Attachment E5_REMINDER POSTCARD.doc Reminder Postcard IC Document
Attachment E6_COVER LETTER FOR FOLLOWUP.doc Cover Letter for Follow-up IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Survey of Health Behaviors for Five-Year Survivors of Colorectal Cancer	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	Survey of Health Behaviors	Attachment E_Survey of Health Behaviors_031809.pdf		No	No	Paper Only

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: 1,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 10 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,000	1,000
Annual IC Time Burden (Hours)	667	667
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Advance Letter for Respondents	Attachment E1_ADVANCE LETTER FOR RESPONDENTS.doc	04/01/2009
California Cancer Registry Brochure	Attachment E2_CCR Brochure.pdf	04/01/2009
Cover Letter for Survey Packet	Attachment E3_COVER LETTER FOR SURVEY PACKET.doc	04/01/2009
Consent Form	Attachment E4_PARTICIPANT CONSENT FORM.doc	04/01/2009
Reminder Postcard	Attachment E5_REMINDER POSTCARD.doc	04/01/2009
Cover Letter for Follow-up	Attachment E6_COVER LETTER FOR FOLLOWUP.doc	04/01/2009

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