Breast Cancer in Young Women Survey

Insurance Coverage, Employment Status, and Copayments/Deductibles Faced by Young Women Diagnosed with Breast Cancer

Documents and Forms

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

Information Collection (IC) Details

IC Title:	Breast Cancer in Young Women Survey	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	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 %

	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

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.