Follow-up Provider Survey

CDC Cervical Cancer Study (CX3)

Documents and Forms

Document Name Document Type
Follow-up Provider Survey Form
Follow-up Provider Survey C1 Follow-up Provider Survey 4 27 2012.doc Form
C1a Cover Letter for Follow-up Provider Survey.docx Provider Cover Letter IC Document

Information Collection (IC) Details

IC Title:	Follow-up Provider Survey	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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	Follow-up Provider Survey	C1 Follow-up Provider Survey 4 27 2012.doc		Yes	No	Paper Only

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title: 09-20-0136 Epidemiologic Studies and Surveillance of Disease Problems	FR Citation: 57 FR 252

Number of Respondents: 70	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	70	4	66
Annual IC Time Burden (Hours)	35	-31	66
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Provider Cover Letter	C1a Cover Letter for Follow-up Provider Survey.docx	05/17/2012

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