Information Collection

Screener for survivors from advocacy groups

IC 220162 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 screener Screener for survivors from advocacy groups	Form
Breast Cancer in Young Women screener - Spanish Screener for survivors from advocacy groups	Form
Breast Cancer in Young Women screener Attachment 4-scr - Intro_Screening for Web-bsed Survey English.pdf	Form
Breast Cancer in Young Women screener - Spanish Attachment 4s-scr - Intro_Screening for Web-bsed Survey Spanish.pdf	Form

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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	none				Yes	Yes	Fillable Fileable
Form	none				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 25

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	25	25
Annual IC Time Burden (Hours)	1	1
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.

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