CIS Email Intake Form (Appendix 2_REV)

Collection of Customer Service, Demographic and Smoking/Tobacco Use Information from NCI Cancer Information Service (CIS) Clients

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0208 can be found here:

Documents and Forms

Document Name Document Type
Form 6 CIS Email Intake Form (Appendix 2_REV) Form and Instruction
6 Email Intake Appendix 2 Email Intake Form.docx Form and Instruction

Information Collection (IC) Details

IC Title:	CIS Email Intake Form (Appendix 2_REV)	Agency IC Tracking Number:

Is this a Common Form? No		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 and Instruction	6	Email Intake	Appendix 2 Email Intake Form.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title: "Records of Participants in Programs and Respondents in Surveys Used to Evaluate Programs of the Public Health Service, HHS/PHS/NIH/OD"	FR Citation: 67 FR 60743

Number of Respondents: 1,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,000	1,000
Annual IC Time Burden (Hours)	33	33
Annual IC Cost Burden (Dollars)	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.