CHIS Cancer Control Module 2011 for Adults (CHIS-CCM)

Change Request for California Health Interview Survey Cancer Control Module (CHIS-CCM) 2011 (NCI)

Documents and Forms

Document Name Document Type
Form 1 CHIS Cancer Control Module 2011 for Adults (CHIS-CCM) Form and Instruction
1 CHIS-CCM 2011 Modified Change Attach 1 CHIS2011-CCM_6-13-2011_v.7.docx Form and Instruction

Information Collection (IC) Details

IC Title:	CHIS Cancer Control Module 2011 for Adults (CHIS-CCM)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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	CHIS-CCM 2011 Modified Change	Attach 1 CHIS2011-CCM_6-13-2011_v.7.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title: SORN No. 09-25-0200 "Clinical, Basic and Population-based Research Studies of the National Institutes of Health (NIH), HHS/NIH/OD"	FR Citation: 67 FR 60776

Number of Respondents: 16,050	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	16,050	16,050
Annual IC Time Burden (Hours)	2,140	2,140
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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