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⚠️ Notice: This information collection may be referencing outdated material.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

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

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Radiation Dose Tool Feedback	Agency IC Tracking Number:	15SN

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection 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 %

	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

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.