Information Collection

CRCCP Clinic-level Information Collection

IC 220791 under ICR 201603-0920-012 · OMB 0920-1074.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1074 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
CRCCP Clinic-level Information Collection	Form
CRCCP Clinic-level Collection Attachment 4a - CRCCP Clinic-Level Collection Instrument (screenshots).pdf	Form
Attachment 4b- CRCCP Clinic-Level Data dictionary_3 24 2016.docx CRCCP Clinic-level Data Dictionary	IC Document
Attachment 4c- CRCCP Clinic-Level Collection Introductory Email.docx Clinic-level collection introductory email	IC Document

IC Title:

CRCCP Clinic-level Information Collection

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

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	CRCCP Clinic-level Collection	Attachment 4a - CRCCP Clinic-Level Collection Instrument (screenshots).pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 31

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

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	372	372
Annual IC Time Burden (Hours)	186	186
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
CRCCP Clinic-level Data Dictionary	Attachment 4b- CRCCP Clinic-Level Data dictionary_3 24 2016.docx	03/28/2016
Clinic-level collection introductory email	Attachment 4c- CRCCP Clinic-Level Collection Introductory Email.docx	03/28/2016

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.