Evaluate Cervical and Lung Cancer Screening Questions

NCHS Questionnaire Design Research Laboratory

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

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

Information Collection (IC) Details

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:

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 %

	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

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.