Assess Breast and Cervical Cancer Screening Program Activities to Expand Access to Screening

Surveys of State, Tribal, Local and Territorial (STLT) Governmental Health Agencies

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0879 can be found here:

Documents and Forms

Document Name Document Type
Assess Breast and Cervical Cancer Screening Program Activities to Expand Access to Screening Form
Assess Breast and Cervical Cancer Screening Program Acti Attachment C - Data Collection Instrument -Web Version.doc Form
Supporting_Statement_A_NBCCEDP 10_29_13.docx Supporting Statement A IC Document
Supporting_Statement_B_NBCCEDP 10_29_13.docx Supporting Statement B IC Document
Attachment A - About the NBCCEDP website.pdf A - About the NBCCEDP Website IC Document
Attachment B - NBCCEDP Framework.pdf B - NBCCEDP Framework IC Document
Attachment D - Data Collection Instrument-Word Version.docx D - Data collection instrument - word version IC Document
Attachment E - Sample Grantee Report.pdf E - Sample Grantee Report IC Document
Attachment F - Sample Management Report.pdf F - Sample Management Report IC Document
Attachment G - Introductory Email 10.28.13.docx G - Intro email IC Document
Attachment H - Reminder Email 10.28.13.docx H - Reminder email IC Document
Attachment I - Follow-Up Email.docx I - Follow-up email IC Document

Information Collection (IC) Details

IC Title:	Assess Breast and Cervical Cancer Screening Program Activities to Expand Access to Screening	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	none	Assess Breast and Cervical Cancer Screening Program Activities	Attachment C - Data Collection Instrument -Web Version.doc		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 67	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	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	67	0	0	0	0	0
Annual IC Time Burden (Hours)	31	0	0	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
Supporting Statement A	Supporting_Statement_A_NBCCEDP 10_29_13.docx	10/31/2013
Supporting Statement B	Supporting_Statement_B_NBCCEDP 10_29_13.docx	10/31/2013
A - About the NBCCEDP Website	Attachment A - About the NBCCEDP website.pdf	10/31/2013
B - NBCCEDP Framework	Attachment B - NBCCEDP Framework.pdf	10/31/2013
D - Data collection instrument - word version	Attachment D - Data Collection Instrument-Word Version.docx	10/31/2013
E - Sample Grantee Report	Attachment E - Sample Grantee Report.pdf	10/31/2013
F - Sample Management Report	Attachment F - Sample Management Report.pdf	10/31/2013
G - Intro email	Attachment G - Introductory Email 10.28.13.docx	10/31/2013
H - Reminder email	Attachment H - Reminder Email 10.28.13.docx	10/31/2013
I - Follow-up email	Attachment I - Follow-Up Email.docx	10/31/2013

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