Information Collection

Requirements Gathering for Patient-Centered Communication (PCC) Web-based Application for NCI

IC 202855 under ICR 201112-0925-001 · OMB 0925-0648.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0648 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 5 Requirements Gathering for Patient-Centered Communication (PCC) Web-based Application for NCI	Form and Instruction
5 System Usability Scale #2_Attach_8_SUScale.docx	Form and Instruction
3 Patient Protocol _2_Attach_6_PatienProtocol_PCCUsability.doc	Form and Instruction
4 Support Person Protocol _2_Attach_7_SupportProtocol_PCCUsability.doc	Form and Instruction
1 Group Interviews Moderator's Guide _1_Attach_1_Group_Inter_Guides_PCC_Require[1].docx	Form and Instruction
2 Individual Interviews Moderator's Guide _1_Attach_2_Provid_Inter_Guide_PCC_Require.docx	Form and Instruction
#1_Attach 3_Consent_Group_PCC_Require.docx #1_Attach 3_Consent_Group_PCC_Require	IC Document
#1_Attach 5_MockUps_Website.docx #1_Attach 5_MockUps_Website	IC Document
#1_Attach 4_Consent_Provider_PCC_Require.docx #1_Attach 4_Consent_Provider_PCC_Require	IC Document
#2 fast-track template Request_PCC_Usability.doc #2 fast-track template Request_PCC_Usability	IC Document
#2_Attach_9_Consent Patient_PCC_Use.docx #2_Attach_9_Consent Patient_PCC_Use	IC Document
#2_Attach_10_Consent_Support_PCC_Use.docx #2_Attach_10_Consent_Support_PCC_Use	IC Document
_1 Fast-track _Request_PCC_Requirements[1].doc _1 Fast-track _Request_PCC_Requirements[1]	IC Document

IC Title:

Requirements Gathering for Patient-Centered Communication (PCC) Web-based Application for NCI

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	5	System Usability Scale	#2_Attach_8_SUScale.docx	Yes	Yes	Printable Only
Form and Instruction	3	Patient Protocol	_2_Attach_6_PatienProtocol_PCCUsability.doc	Yes	Yes	Printable Only
Form and Instruction	4	Support Person Protocol	_2_Attach_7_SupportProtocol_PCCUsability.doc	Yes	Yes	Printable Only
Form and Instruction	1	Group Interviews Moderator's Guide	_1_Attach_1_Group_Inter_Guides_PCC_Require[1].docx	Yes	Yes	Printable Only
Form and Instruction	2	Individual Interviews Moderator's Guide	_1_Attach_2_Provid_Inter_Guide_PCC_Require.docx	Yes	Yes	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 65

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

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	65	0	0	0	0	0
Annual IC Time Burden (Hours)	65	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
#1_Attach 3_Consent_Group_PCC_Require	#1_Attach 3_Consent_Group_PCC_Require.docx	06/22/2012
#1_Attach 5_MockUps_Website	#1_Attach 5_MockUps_Website.docx	06/22/2012
#1_Attach 4_Consent_Provider_PCC_Require	#1_Attach 4_Consent_Provider_PCC_Require.docx	06/22/2012
#2 fast-track template Request_PCC_Usability	#2 fast-track template Request_PCC_Usability.doc	06/22/2012
#2_Attach_9_Consent Patient_PCC_Use	#2_Attach_9_Consent Patient_PCC_Use.docx	06/22/2012
#2_Attach_10_Consent_Support_PCC_Use	#2_Attach_10_Consent_Support_PCC_Use.docx	06/22/2012
_1 Fast-track _Request_PCC_Requirements[1]	_1 Fast-track _Request_PCC_Requirements[1].doc	06/22/2012

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