Information Collection

Breast Cancer in Young Women screener and survey - survivors from advocacy groups

IC 220163 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 and survey - survivors from advocacy groups	Form
Sceener Attachment 4-scr - Intro_Screening for Web-bsed Survey English.pdf	Form
Screener - Spanish Attachment 4s-scr - Intro_Screening for Web-bsed Survey Spanish.pdf	Form
Breast Cancer in Young Women Survey Attachment 4 - Web-based Survey Instrument English_20160212.pdf	Form
Breast Cancer in Young Women Survey - Spanish Attachment 4s - Web-based Survey Instrument Spanish_20160212.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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	none	Sceener	Attachment 4-scr - Intro_Screening for Web-bsed Survey English.pdf	Yes	Yes	Fillable Fileable
Form	none	Screener - Spanish	Attachment 4s-scr - Intro_Screening for Web-bsed Survey Spanish.pdf	Yes	Yes	Fillable Fileable
Form	none	Breast Cancer in Young Women Survey	Attachment 4 - Web-based Survey Instrument English_20160212.pdf	Yes	Yes	Fillable Fileable
Form	none	Breast Cancer in Young Women Survey - Spanish	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: 2,000

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	2,000	2,000
Annual IC Time Burden (Hours)	800	800
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.