Information Collection

Sub-Study #15: The Surveillance, Epidemiology, and End Results (SEER) Residual Tissue Repository Program: Survey to Assess Service Delivery and Product Quality

IC 203874 under ICR 201108-0925-002 · OMB 0925-0642.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0642 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Sub-Study #15: The Surveillance, Epidemiology, and End Results (SEER) Residual Tissue Repository Program: Survey to Assess Service Delivery and Product Quality	Form and Instruction
1 RTR Survey #15_Attach 3_RTR survey screenshots.pdf	Form and Instruction
#15_SEER RTR_Fast-Track_Request_8_17_2012.doc #15_SEER RTR_Fast-Track_Request_8_17_2012	IC Document
#15_Attach 1_RTR survey Word.doc #15_Attach 1_RTR survey Word	IC Document
#15_Attach 2_RTR_Invitiation Letter.doc #15_Attach 2_RTR_Invitiation Letter	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Sub-Study #15: The Surveillance, Epidemiology, and End Results (SEER) Residual Tissue Repository Program: Survey to Assess Service Delivery and Product Quality

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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	1	RTR Survey	#15_Attach 3_RTR survey screenshots.pdf		Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 72

Number of Respondents for Small Entity: 9

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

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	72	0	0	0	0	0
Annual IC Time Burden (Hours)	6	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
#15_SEER RTR_Fast-Track_Request_8_17_2012	#15_SEER RTR_Fast-Track_Request_8_17_2012.doc	08/20/2012
#15_Attach 1_RTR survey Word	#15_Attach 1_RTR survey Word.doc	08/20/2012
#15_Attach 2_RTR_Invitiation Letter	#15_Attach 2_RTR_Invitiation Letter.doc	08/20/2012

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