Information Collection

Radiation Dose Tool Feedback

IC 215833 under ICR 201305-0923-003 · OMB 0923-0047.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0923-0047 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
ATT C RDT Public Screener.docx	Other-WORD
ATT D RDT PIO and Public Planners Screener.docx	Other-WORD
ATT F RDT Interview Guide for Public.docx	Other-WORD
ATT G RDT Interview Guide for Public Health.docx	Other-WORD
Service Delivery GenIC Request Form_Radiation Dose Tool Feedback.pdf Request for Approval	IC Document
ATT A RDT Protocol Summary.docx Att A: Protocol Summary	IC Document
ATT B RDT Protocol.docx Att B_Protocol	IC Document
ATT E Participant Info Sheet.docx Att E: Participant Information Sheet	IC Document
Appendix H Radiation Dose Tool.pptx Att H: Radiation Dose Tool	IC Document

IC Title:

Radiation Dose Tool Feedback

Agency IC Tracking Number:

15SN

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-WORD	ATT C RDT Public Screener.docx	Yes	Yes	Fillable Printable
Other-WORD	ATT D RDT PIO and Public Planners Screener.docx	Yes	Yes	Fillable Printable
Other-WORD	ATT F RDT Interview Guide for Public.docx	Yes	Yes	Fillable Printable
Other-WORD	ATT G RDT Interview Guide for Public Health.docx	Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 108

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 50 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	108	108
Annual IC Time Burden (Hours)	48	48
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Request for Approval	Service Delivery GenIC Request Form_Radiation Dose Tool Feedback.pdf	03/24/2015
Att A: Protocol Summary	ATT A RDT Protocol Summary.docx	03/24/2015
Att B_Protocol	ATT B RDT Protocol.docx	03/24/2015
Att E: Participant Information Sheet	ATT E Participant Info Sheet.docx	03/24/2015
Att H: Radiation Dose Tool	Appendix H Radiation Dose Tool.pptx	03/24/2015

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