Attach2A_Gen Sub-Study Form

GENERIC SUB-STUDY SUBMISSION – 0925-XXXX, Expiration Date xx/xx/20xx

DATE OF REQUEST: Date

SUB AGENCY (I/C): NIH/NCI/Division

TITLE OF SUB-STUDY: Title

GENERIC CLEARANCE UNDER OMB #0925-xxxx-xx EXP. DATE: xx/xx/20xx

TOTAL ANNUAL BURDEN APPROVED: X hours

BURDEN APPROVED TO DATE: X hours

BURDEN FOR THIS REQUEST: X hours

ABSTRACT:

Briefly describe the information collection including background, purpose, why it is needed, use to which it will be put, type of participants, methodology and research instrument or form.

This form should be 1 page.

IS RACE AND ETHNICITY DATA COLLECTED AS REQUIRED? ______YES _____NO_______N/A	IS PERSONALLY IDENTIFIABLE INFORMATION (PII) BEING COLLECTED? ______YES _____NO_______N/A
OBLIGATION TO RESPOND: _____ VOLUNTARY ______ REQUIRED TO OBTAIN OR RETAIN BENEFITS ______ MANDATORY	TYPE OF COLLECTION/RESEARCH (Check one or more)? _____CUSTOMER SATISFACTION _____USABILITY TESTING _____FOCUS GROUPS _____PRETESTING _____FORMATIVE RESEARCH _____QUESTIONNAIRE DEVELOPMENT _____PERFORMANCE MEASUREMENT _____PROGRAM MONITORING _____OTHER: _________________________
HOW WILL THIS SURVEY BE OFFERED? _____ WEB SITE _____ TELEPHONE INTERVIEW _____ MAIL RESPONSE _____ IN PERSON INTERVIEW _____ OTHER: _________________________
CONTACT INFORMATION: NAME: Name TELEPHONE NUMBER: ? EMAIL ADDRESS: ?