NLM CervigramFinder and Boundary Marking Tool

Request for Generic Clearance to Conduct Voluntary Customer/Partner Surveys(NLM)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0476 can be found here:

Documents and Forms

Document Name Document Type
Form 1 NLM CervigramFinder and Boundary Marking Tool Form and Instruction
1 survey NLM LHC Physician Cervigram Survey.docx Form and Instruction
NLM LHC Cervigram Generic Clearance Request Form.doc NLM LHC Cervigram Generic Clearance Request Form IC Document
NLM LHC Cervigram Mini Supporting Statement.docx NLM LHC Cervigram Mini Supporting Statement IC Document

Information Collection (IC) Details

IC Title:	NLM CervigramFinder and Boundary Marking Tool	Agency IC Tracking Number:

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	survey	NLM LHC Physician Cervigram Survey.docx		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 400	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	400	0	0	0	0	0
Annual IC Time Burden (Hours)	33	0	0	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
NLM LHC Cervigram Generic Clearance Request Form	NLM LHC Cervigram Generic Clearance Request Form.doc	02/23/2010
NLM LHC Cervigram Mini Supporting Statement	NLM LHC Cervigram Mini Supporting Statement.docx	02/23/2010

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