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Cx3 Study - Patient Enrollment Form
CDC Cervical Cancer Study (CX3)
OMB: 0920-0814
IC ID: 188626
OMB.report
HHS/CDC
OMB 0920-0814
ICR 201205-0920-008
IC 188626
( )
Documents and Forms
Document Name
Document Type
Att E1d_Patient enrollment form_0209.doc
Other-WORD
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Cx3 Study - Patient Enrollment Form
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
Removed
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
Other-WORD
Att E1d_Patient enrollment form_0209.doc
Yes
Yes
Fillable Printable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Illness Prevention
Privacy Act System of Records
Title:
09-20-0136 Epidemiologic Studies and Surveillance of Disease Problems
FR Citation:
57 FR 252
Number of Respondents:
2,667
Number of Respondents for Small Entity:
0
Affected Public:
State, Local, and Tribal Governments
Percentage of Respondents Reporting Electronically:
0 %
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
0
0
-2,667
0
0
2,667
Annual IC Time Burden (Hours)
0
0
-222
0
0
222
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
No associated records found
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.
