Information Collection

FEMALE Participants Survivor Questionnaire - Module A

IC 216621 under ICR 201505-0920-002 · OMB 0920-1064.

Documents and Forms

Document Name Document Type
FEMALE Participants Survivor Questionnaire - Module A Form and Instruction
Survivor Questionnaire - Pilot/A/B Att5_SurvivorQuestionnaire 20150518 clean.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	FEMALE Participants Survivor Questionnaire - Module A	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
Form and Instruction	None	Survivor Questionnaire - Pilot/A/B	Att5_SurvivorQuestionnaire 20150518 clean.docx	None	No		Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 175	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	175	175
Annual IC Time Burden (Hours)	88	88
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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