Information Collection

Bundled Sub-study #11, 12 and #13 (#11 Mentorship Program; #12 Medical Oncologist Practice of Care; #13 Nightshift Work and Sleep in China)

IC 197264 under ICR 201008-0925-004 · OMB 0925-0046.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0046 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Mentee Application and Competancy Assessment Bundled Sub-study #11, 12 and #13 (#11 Mentorship Program; #12 Medical Oncologist Practice of Care; #13 Nightshift Work and Sleep in China)	Form and Instruction
Form 2 MISC Survey Bundled Sub-study #11, 12 and #13 (#11 Mentorship Program; #12 Medical Oncologist Practice of Care; #13 Nightshift Work and Sleep in China)	Form
Form 3 Nightshift and Sleep Qx. Bundled Sub-study #11, 12 and #13 (#11 Mentorship Program; #12 Medical Oncologist Practice of Care; #13 Nightshift Work and Sleep in China)	Form and Instruction
1 Mentee Application and Competancy Assessment #11C_R2R Mentee Application.docx	Form and Instruction
2 MISC Survey # 12_Attach 12B Web-based Survey_MIBC pdf - Adobe Reader.pdf	Form
3 Nightshift and Sleep Qx. #13_Qx_NightShift.doc	Form and Instruction
Bundle Gen IC Form_11-12-13-R2R_MISC_Nightshift.doc Bundle Gen IC Form_11-12-13-R2R_MISC_Nightshift	IC Document
#11_OMB_Justif Memo_R2R_FINAL (2).docx #11_OMB_Justif Memo_R2R_FINAL (2)	IC Document
#12_Justi Memo_MIBC-3-25-11_Rev.doc #12_Justi Memo_MIBC-3-25-11_Rev	IC Document
#13_Justif Memo_NightShift.doc #13_Justif Memo_NightShift	IC Document
Memo to OMB_Key To Bundle #11, 12 & 13.doc Memo to OMB_Key To Bundle #11, 12 & 13	IC Document

IC Title:

Bundled Sub-study #11, 12 and #13 (#11 Mentorship Program; #12 Medical Oncologist Practice of Care; #13 Nightshift Work and Sleep in China)

Agency IC Tracking Number:

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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	1	Mentee Application and Competancy Assessment	#11C_R2R Mentee Application.docx	Yes	Yes	Fillable Fileable
Form	2	MISC Survey	# 12_Attach 12B Web-based Survey_MIBC pdf - Adobe Reader.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	3	Nightshift and Sleep Qx.	#13_Qx_NightShift.doc	No	No	Paper Only

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title: SORN #09-25-0156, "Records of Participants in Used to Evaluate Programs of the Public Health Service, HHS/PHS/NIH/OD"

FR Citation: 67 FR 60743

Number of Respondents: 456

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 34 %

table that charts list of burden
	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	456	0	0	0	0	0
Annual IC Time Burden (Hours)	118	0	0	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Bundle Gen IC Form_11-12-13-R2R_MISC_Nightshift	Bundle Gen IC Form_11-12-13-R2R_MISC_Nightshift.doc	03/25/2011
#11_OMB_Justif Memo_R2R_FINAL (2)	#11_OMB_Justif Memo_R2R_FINAL (2).docx	03/25/2011
#12_Justi Memo_MIBC-3-25-11_Rev	#12_Justi Memo_MIBC-3-25-11_Rev.doc	03/25/2011
#13_Justif Memo_NightShift	#13_Justif Memo_NightShift.doc	03/25/2011
Memo to OMB_Key To Bundle #11, 12 & 13	Memo to OMB_Key To Bundle #11, 12 & 13.doc	03/25/2011

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