Information Collection

Breast Cancer in Young Women Survey

IC 220161 under ICR 201602-0920-011 · OMB 0920-1123.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Breast Cancer in Young Women Survey	Form and Instruction
Breast Cancer in Young Women Attachment 3 - Mail-in Survey English_20160216.docx	Form and Instruction
Breast Cancer in Young Women - Spanish Attachment 3s - Mail-in Survey Spanish_20160216.docx	Form and Instruction
Breast Cancer in Young Women - online survey Attachment 4 - Web-based Survey Instrument English_20160212.pdf	Form and Instruction
Breast Cancer in Young Women - Spanish online survey Attachment 4s - Web-based Survey Instrument Spanish_20160212.pdf	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	none	Breast Cancer in Young Women	Attachment 3 - Mail-in Survey English_20160216.docx	No		Paper Only
Form and Instruction	none	Breast Cancer in Young Women - Spanish	Attachment 3s - Mail-in Survey Spanish_20160216.docx	No		Paper Only
Form and Instruction	none	Breast Cancer in Young Women - online survey	Attachment 4 - Web-based Survey Instrument English_20160212.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	none	Breast Cancer in Young Women - Spanish online survey	Attachment 4s - Web-based Survey Instrument Spanish_20160212.pdf	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,200

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 50 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,200	1,200
Annual IC Time Burden (Hours)	440	440
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.