Information Collection

Evaluate Cervical and Lung Cancer Screening Questions

IC 215946 under ICR 201205-0920-001 · OMB 0920-0222.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0222 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Evaluate Cervical and Lung Cancer Screening Questions	Form
Screener Attach 3 - Phone Screener.docx	Form
Questionnaire Attach 1 - Qnne.docx	Form
0920-0222 QDRL Cervlung2 032715.docx Request for Approval	IC Document
Attach 2 - Adflyer-updated.docx Flyer	IC Document
Attach 4 - Informed Consent.docx Informed Consent	IC Document
Attach 5 - Special Consent.docx Special Consent	IC Document

IC Title:

Evaluate Cervical and Lung Cancer Screening Questions

Agency IC Tracking Number:

15YZ

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	none	Screener	Attach 3 - Phone Screener.docx		No		Fillable Printable
Form	none	Questionnaire	Attach 1 - Qnne.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: 09-20-0164 Health and Demographic Surveys Conducted in Probability Samples of the U.S. Population

FR Citation: 49 FR 37693

Number of Respondents: 112

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 Agency Discretion
Annual Number of Responses for this IC	112	112
Annual IC Time Burden (Hours)	46	46
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Request for Approval	0920-0222 QDRL Cervlung2 032715.docx	04/02/2015
Flyer	Attach 2 - Adflyer-updated.docx	04/02/2015
Informed Consent	Attach 4 - Informed Consent.docx	04/02/2015
Special Consent	Attach 5 - Special Consent.docx	04/02/2015

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