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

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 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

Information Collection (IC) Details

IC Title:	Breast Cancer in Young Women screener and survey - survivors from advocacy groups	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	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 %

	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

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.