MIS for Comprehensive Cancer Control Programs

Form: Approved

OMB No.: 0920-XXXX

Exp. Date: xx/xx/xxxx

NCCDPHP MIS CCC Proposed Screens

Public reporting burden of this collection of information is estimated to average 6 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, GA 30333; ATTN: PRA (0920-XXXX)

Program Information: Contact Information

Program Information: Program Summary

Resources: Personnel

Resources: Partnership/Coalition:

Resources: Partnership/Coalition (continued):

Resources: Partnership/Coalition (continued):

Resources: Contractors

Financial: Cost Sharing

Financial: In-Kind

Planning: Standard Data Sources

Planning: Other Data Sources

Planning: Plans and Logic Models

Action Plan: Project Period Objective

Action Plan: Annual Objective

Action Plan: Annual Objective Continued:

Action Plan: Annual Objective Continued:

Action Plan: Annual Objective Continued:

Action Plan: Annual Activity

Action Plan: Objective Progress (for both Project Period and Annual objectives)

Action Plan: Products

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