Case Studies to Explore Interventions to Support, Build, and Provide Legacy Awareness for Young Breast Cancer Survivors

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Sup Sta B_13ZC.doc	Supporting Statement B	Uploaded 2014-02-10	Available
Att 12_IRB Approval and Findings.pdf	Supplementary Document	Uploaded 2014-02-17	Available
Att 6c_Introductory Email_9.11.13.docx	Supplementary Document	Uploaded 2014-02-17	Available
Att 6b_Introductory Letter_12.18.13.docx	Supplementary Document	Uploaded 2014-02-17	Available
Att 6a_ Data Collector Non-disclosure_12.18.13.docx	Supplementary Document	Uploaded 2014-02-10	Repair queued
Att 5_Sim and Diff Across Case Types_9.11.13.docx	Supplementary Document	Uploaded 2014-02-10	Available
Att 4_Selection Criteria Matrix_12.17.13.docx	Supplementary Document	Uploaded 2014-02-10	Available
Att 3_Case Study Framework_12.16.13.docx	Supplementary Document	Uploaded 2014-02-10	Available
Att 2_60dy FRN.pdf	Supplementary Document	Uploaded 2014-02-10	Available
Att 1b_PHSA.doc	Supplementary Document	Uploaded 2014-02-10	Available
Att 1a_ACA section 10413.pdf	Supplementary Document	Uploaded 2014-02-10	Available
Att 9_Informed Consent_12.18.13.docx	Supplementary Document	Uploaded 2014-02-10	Available
Att 8_Interview Guide Matrix_12.18.13.docx	Supplementary Document	Uploaded 2014-02-10	Available
Att 7b_Observation Form_9.11.13.docx	Supplementary Document	Uploaded 2014-02-10	Available
Att 7a_Document Review Form_9.11.13.docx	Supplementary Document	Uploaded 2014-02-10	Available
Att 6d_Site Visit Preparation Call_02.10.2014.docx	Supplementary Document	Uploaded 2014-02-10	Available
Att 9_Informed Consent_12.18.13.docx	Supplementary Document	Uploaded 2014-02-10	Repair queued
Att 8_Interview Guide Matrix_12.18.13.docx	Supplementary Document	Uploaded 2014-02-10	Available
Att 7b_Observation Form_9.11.13.docx	Supplementary Document	Uploaded 2014-02-10	Available
Att 7a_Document Review Form_9.11.13.docx	Supplementary Document	Uploaded 2014-02-10	Available
Att 6d_Site Visit Preparation Call_02.10.2014.docx	Supplementary Document	Uploaded 2014-02-10	Available
Att 9_Informed Consent_12.18.13.docx	Supplementary Document	Uploaded 2014-02-10	Available
Att 8_Interview Guide Matrix_12.18.13.docx	Supplementary Document	Uploaded 2014-02-10	Available
Att 7b_Observation Form_9.11.13.docx	Supplementary Document	Uploaded 2014-02-10	Available
Att 7a_Document Review Form_9.11.13.docx	Supplementary Document	Uploaded 2014-02-10	Available
Att 6d_Site Visit Preparation Call_02.10.2014.docx	Supplementary Document	Uploaded 2014-02-10	Available
Att 6c_Introductory Email_9.11.13.docx	Supplementary Document	Uploaded 2014-02-10	Available
Att 6b_Introductory Letter_12.18.13.docx	Supplementary Document	Uploaded 2014-02-10	Available
Att 9_Informed Consent_12.18.13.docx	Supplementary Document	Uploaded 2014-02-10	Available
Att 8_Interview Guide Matrix_12.18.13.docx	Supplementary Document	Uploaded 2014-02-10	Available
Att 7b_Observation Form_9.11.13.docx	Supplementary Document	Uploaded 2014-02-10	Available
Att 7a_Document Review Form_9.11.13.docx	Supplementary Document	Uploaded 2014-02-10	Available
Att 6d_Site Visit Preparation Call_02.10.2014.docx	Supplementary Document	Uploaded 2014-02-10	Available
Att 9_Informed Consent_12.18.13.docx	Supplementary Document	Uploaded 2014-02-10	Available
Att 8_Interview Guide Matrix_12.18.13.docx	Supplementary Document	Uploaded 2014-02-10	Available
Att 7b_Observation Form_9.11.13.docx	Supplementary Document	Uploaded 2014-02-10	Available
Att 7a_Document Review Form_9.11.13.docx	Supplementary Document	Uploaded 2014-02-10	Available
Att 6d_Site Visit Preparation Call_02.10.2014.docx	Supplementary Document	Uploaded 2014-02-10	Available
Sup Sta A_13ZC.doc	Supporting Statement A	Uploaded 2014-02-10	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
210406	IDI Guide for Program Partners (Gov't Sector)	Other-WORD	New
210405	IDI Guide for Program Staff Members (Gov't Sector)	Other-WORD	New
210404	IDI Guide for Program Managers	Other-WORD	New
210403	IDI Guide for Program Directors/Principal Investigators (Gov't Sector)	Other-WORD	New
210402	Worksheet for Scheduling Site Visit Interviews (Gov't Sector)	Other-WORD	New
210401	Worksheet for Identifying Site Visit Interviews (Gov't Sector)	Other-WORD	New
210400	IDI Guide for Program Partners (Private Sector)	Other-WORD	New
210399	IDI Guide for Program Staff Members (Private Sector)	Other-WORD	New
210398	IDI Guide for Program Managers (Private Sector)	Other-WORD	New
210397	IDI Guide for Program Directors/Principal Investigators (Private Sector)	Other-WORD	New
210396	Worksheets for Scheduling Site Visit Interviews (Private Sector)	Other-WORD	New
210395	Worksheet for Identifying Site Visit Interviews (Private Sector)	Other-WORD	New

ICR Details

OMB Control No: 0920-1012	ICR Reference No: 201402-0920-013
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CDC	Agency Tracking No: 21423
Title: Case Studies to Explore Interventions to Support, Build, and Provide Legacy Awareness for Young Breast Cancer Survivors
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 04/07/2014
	Date Received in OIRA: 02/19/2014
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	04/30/2015	12 Months From Approved
Responses	144	0	0
Time Burden (Hours)	168	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: This is a new ICR. CDC plans to conduct exploratory case studies of up to 12 organizations that develop or deliver support services and/or educational materials for women who are young breast cancer survivors. Some organizations receive CDC funding for these activities and some organizations do not receive CDC funding for these activities. Information will be collected through in-depth interviews of program staff.

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Authorizing Statute(s): PL: Pub.L. 111 - 148 10413 Name of Law: Young Women's Breast Health Education and Awareness Requires Learning Young Act of 2009
   US Code: 42 USC 301 Name of Law: Public Health Service Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 42076	07/15/2013
30-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 8721	02/13/2014
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 12

table that charts list of burden

IC Title	Form No.	Form Name
Worksheet for Identifying Site Visit Interviews (Private Sector)
Worksheets for Scheduling Site Visit Interviews (Private Sector)
IDI Guide for Program Directors/Principal Investigators (Private Sector)
IDI Guide for Program Managers (Private Sector)
IDI Guide for Program Staff Members (Private Sector)
IDI Guide for Program Partners (Private Sector)
Worksheet for Identifying Site Visit Interviews (Gov't Sector)
Worksheet for Scheduling Site Visit Interviews (Gov't Sector)
IDI Guide for Program Directors/Principal Investigators (Gov't Sector)
IDI Guide for Program Managers
IDI Guide for Program Staff Members (Gov't Sector)
IDI Guide for Program Partners (Gov't Sector)

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ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	144	0	0	144	0	0
Annual Time Burden (Hours)	168	0	0	168	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: This is a new information collection request. Data are not available from other sources.

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Annual Cost to Federal Government: $658,695

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Yes

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 02/19/2014

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