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

Documents and forms in this information collection
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

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.