Colonoscopy Questionnaire

Colorectal Cancer Control Program Indirect/Non-Medical Cost Study

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0963 can be found here:

Documents and Forms

Document Name Document Type
Att_G(english).Colonoscopy_questionnaire_screens.pdf Other-WORD
Att_G(spanish).Colonoscopy_questionnaire_screens.pdf Other-WORD
Att D. COL protocol instructions.docx Att D IC Document

Information Collection (IC) Details

IC Title:	Colonoscopy Questionnaire	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
Other-WORD			Att_G(english).Colonoscopy_questionnaire_screens.pdf		Yes	Yes	Fillable Printable
Other-WORD			Att_G(spanish).Colonoscopy_questionnaire_screens.pdf		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 315	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 20 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	315	315
Annual IC Time Burden (Hours)	131	131
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Att D	Att D. COL protocol instructions.docx	12/10/2012

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