Worksheet for Scheduling Site Visit Interviews (Gov't Sector)

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

Documents and Forms

Document Name Document Type
Att 6f_Worksheet for Scheduling Interviews_12.17.13.docx Other-WORD
Att 6e_Worksheet for Identifying Interviewees_12.17.13.docx Other-WORD
Att 6d_Site Visit Preparation Call_02.10.2014.docx Att 6d_Site Visit Preparation Call_02 IC Document
Att 7a_Document Review Form_9.11.13.docx Att 7a_Document Review Form_9 IC Document
Att 7b_Observation Form_9.11.13.docx Att 7b_Observation Form_9 IC Document
Att 8_Interview Guide Matrix_12.18.13.docx Att 8_Interview Guide Matrix_12 IC Document
Att 9_Informed Consent_12.18.13.docx Att 9_Informed Consent_12 IC Document

Information Collection (IC) Details

IC Title:	Worksheet for Scheduling Site Visit Interviews (Gov't Sector)	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 6f_Worksheet for Scheduling Interviews_12.17.13.docx		Yes	Yes	Fillable Printable
Other-WORD			Att 6e_Worksheet for Identifying Interviewees_12.17.13.docx		No	No	Fillable Fileable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 5	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	5	5
Annual IC Time Burden (Hours)	10	10
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Att 6d_Site Visit Preparation Call_02	Att 6d_Site Visit Preparation Call_02.10.2014.docx	02/10/2014
Att 7a_Document Review Form_9	Att 7a_Document Review Form_9.11.13.docx	02/10/2014
Att 7b_Observation Form_9	Att 7b_Observation Form_9.11.13.docx	02/10/2014
Att 8_Interview Guide Matrix_12	Att 8_Interview Guide Matrix_12.18.13.docx	02/10/2014
Att 9_Informed Consent_12	Att 9_Informed Consent_12.18.13.docx	02/10/2014

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