CTEP Support Contracts Forms and Surveys (NCI)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 77 ETCTN	Form	New	Available
Form 76 ETCTN PI Survey	Form	New	Available
Form 75 low accuring survey	Form	New	Available
Form 74 Prospective Survey	Form	New	Available
Form 73 Concept Survey	Form	New	Available
Form 72 PIO External Survey	Form	New	Available
Form 71 Annual CIRB Board Assessment	Form	New	Available
Form 70 CIRB Website Focus Group Survey -Web site usability testing	Form	New	Available
Form 69 CIRB Website Focus Group Survey - Network Groups usability	Form	New	Available
Form 68 CIRB Website Focus Group Survey - Local Instiutions usability	Form	New	Available
Form 67 CIRB Website Focus Group Survey - CIRB Members usability	Form	New	Available
Form 66 CIRB FUP Survey	Form	New	Available
Form 65 CIRB Satisfaction survey	Form	New	Available
Form 64 OPEN survey	Form	New	Available
Form 63 Help Desk Survey	Form and Instruction	New	Available
Form 62 websurvey final	Form	New	Available
Form 61 Change PI Worksheet	Form and Instruction	New	Repair queued
Form 60 Unanticipated Problem Worksheet	Form and Instruction	New	Repair queued
Form 59 Study Closure Worksheet	Form and Instruction	New	Available
Form 58 SSW Worksheet	Form and Instruction	New	Available
Form 57 Annual PI Worksheet	Form and Instruction	New	Repair queued
Form 56 Annual SI Worksheet	Form and Instruction	New	Available
Form 55 Reviewer Worksheet CPC UP FB	Form and Instruction	New	Available
Form 54 Reviewer Worksheet ER IR	Form and Instruction	New	Available
Form 53 Reviewer Worksheet SCR ER	Form and Instruction	New	Available
Form 52 reviewer Worksheet ER ClosureWksht	Form and Instruction	New	Available
Form 51 Reviewer Worksheet Recruitment materials	Form and Instruction	New	Available
Form 50 Reviewer Worksheet Translated Docs	Form and Instruction	New	Repair queued
Form 49 CIRB App for Translated Docs	Form and Instruction	New	Available
Form 48 reviewer Worksheet CIRB Stat	Form and Instruction	New	Available
Form 47 Reviewer Worksheet UP FB	Form and Instruction	New	Available
Form 46 Ped Exped Chair Resp Req Mods	Form and Instruction	New	Available
Form 45 Adult & CPC Exped Chair Resp Req Mods	Form and Instruction	New	Available
Form 44 Ped FB SCRWksht	Form and Instruction	New	Available
Form 43 Adult & CPC FB SCRWksht	Form and Instruction	New	Available
Form 42 Ped Expedited CR Worksheet	Form and Instruction	New	Available
Form 41 Adult & CPC Expedited CR Worksheet	Form and Instruction	New	Available
Form 40 Ped Expedited Reviewer Worksheet	Form and Instruction	New	Available
Form 39 Adult & CPC Expedited Reviewer Worksheet	Form and Instruction	New	Available
Form 38 CPC FB Pharma Reviewer Worksheet	Form and Instruction	New	Available
Form 37 Adult Ped FB Pharma Adult Reviewer Worksheet	Form and Instruction	New	Available
Form 36 Ped AR FB Reviewer Worksheet	Form and Instruction	New	Available
Form 35 Adult AR FB Reviewer Worksheet	Form and Instruction	New	Available
Form 34 Oed CR FB Reviewer Worksheet	Form and Instruction	New	Available
Form 33 Adult CR FB Reviewer Worksheet	Form and Instruction	New	Available
Form 32 Ped IR FB Reviewerworksheet	Form and Instruction	New	Available
Form 31 Adult IR FB Reviewer Worksheet	Form and Instruction	New	Available
Form 30 CIRB CR Application	Form and Instruction	New	Available
Form 29 CIRB Ancillary Application	Form and Instruction	New	Available
Form 28 CIRB AR Application	Form and Instruction	New	Available
Form 27 CIRB IR Exempt Application	Form and Instruction	New	Available
Form 26 CIRB IR Application	Form and Instruction	New	Available
Form 25 COI Screening	Form and Instruction	New	Repair queued
Form 24 COI Screen	Form and Instruction	New	Available
Form 23 CIRB Direct Deposit Form	Form	New	Available
Form 22 CIRB Member NDA	Form and Instruction	New	Available
Form 21 CIRB ContactInfoForm	Form and Instruction	New	Available
Form 20 CIRB Biosketch Questions CIRB member	Form and Instruction	New	Available
Form 19 NCI CIRB Signatory Enrollment Form	Form and Instruction	New	Available
Form 18 NCI CIRB AA DivofResps	Form and Instruction	New	Available
Form 17 System Access Request form	Form and Instruction	New	Available
Form 16 Transfer	Form and Instruction	New	Available
Form 15 Patient Enrollment Transmittal form	Form and Instruction	New	Available
Form 14 TAILORx UDM	Form and Instruction	New	Repair queued
Form 13 TAILORx PACCT1_DTF	Form and Instruction	New	Available
Form 12 Generic Data	Form and Instruction	New	Available
Form 11 8233 Form	Form and Instruction	New	Repair queued
Form 10 RTOG0834	Form and Instruction	New	Available
Form 9 Data Clarification Form	Form and Instruction	New	Available
Form 8 Site Data Update form	Form and Instruction	New	Available
Form 7 Supply	Form and Instruction	New	Available
Form 6 Clinical Brochure	Form and Instruction	New	Available
Form 5 Roster Update	Form and Instruction	New	Available
Form 4 Site Addition	Form and Instruction	New	Available
Form 3 Withdrawl form	Form and Instruction	New	Available
Form 2 IRB Certification	Form and Instruction	New	Available
Form 1 IRB Transmittal	Form and Instruction	New	Available
30dayFRN2017-04253.pdf	Supplementary Document	Uploaded 2017-03-07	Available
attachment_D07 - CIRB - Privacy Act Memo_10_2009.pdf	Supplementary Document	Uploaded 2017-03-03	Available
attachment_D06 - CIRB - Emmes IRB_exempt_09_2016.pdf	Supplementary Document	Uploaded 2017-03-03	Repair queued
attachment_D05 - CIRB - OHSR Determination.pdf	Supplementary Document	Uploaded 2017-03-03	Available
attachment_D04 - CIRB_FIPS_199_09_2015.pdf	Supplementary Document	Uploaded 2017-03-03	Available
attachment_D03_privacy act memo.pdf	Supplementary Document	Uploaded 2017-03-03	Available
attachment_D02_irb and OHSR determination.pdf	Supplementary Document	Uploaded 2017-03-03	Available
attachment_D01_CTSU_PIA.pdf	Supplementary Document	Uploaded 2017-03-03	Available
SSA CTEP Support Contracts Forms and Surveys_Final.docx	Supporting Statement A	Uploaded 2017-05-31	Available
SSB CTEP.docx	Supporting Statement B	Uploaded 2017-02-28	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
225931	ETCTN RS Survey (Attachment C13)	Form	New	ETCTN
225930	ETCTN PI Survey (Attachment C12)	Form	New	ETCTN PI Survey
225929	Low Accural clinical Trial Survey (Attachment C11)	Form	New	low accuring survey
225928	Prospective Clinical Trial Survey (Attachment C10)	Form	New	Prospective Survey
225927	Concept Clinical Trial Survey (Attachment C9)	Form	New	Concept Survey
225926	PIO Customer Satisfaction Survey (Attachment C8)	Form	New	PIO External Survey
225925	CIRB Board member Annual Assessment Survey (Attachment C7)	Form	New	Annual CIRB Board Assessment
225924	Website Focus Groups, Communication Project (Attachments C6 A-D)	Form	New	CIRB Website Focus Group Survey -Web site usability testing
225924	Website Focus Groups, Communication Project (Attachments C6 A-D)	Form	New	CIRB Website Focus Group Survey - Network Groups usability
225924	Website Focus Groups, Communication Project (Attachments C6 A-D)	Form	New	CIRB Website Focus Group Survey - Local Instiutions usability
225924	Website Focus Groups, Communication Project (Attachments C6 A-D)	Form	New	CIRB Website Focus Group Survey - CIRB Members usability
225923	Follow-up survey (Communication Audit) (Attachment C5)	Form	New	CIRB FUP Survey
225922	CIRB Customer Satisfaction survey (Attachment C4)	Form	New	CIRB Satisfaction survey
225921	CTSU OPEN Survey (Attachment C3)	Form	New	OPEN survey
225919	CTSU Help Desk Customer Satisfaction Survey (Attachment C2)	Form and Instruction	New	Help Desk Survey
225918	CTSU Website Customer Satisfaction Survey (Attachment C1)	Form	New	websurvey final
225917	Change of SI PI Form (Attachment B45)	Form and Instruction	New	Change PI Worksheet
225916	UP or SCN Reporting Form (Attachment B44)	Form and Instruction	New	Unanticipated Problem Worksheet
225915	Study Closure or Transfer of Study Review Responsibility Form (Attachment B43)	Form and Instruction	New	Study Closure Worksheet
225914	Study-Specific worksheet About Local Context (Attachment B42)	Form and Instruction	New	SSW Worksheet
225913	Annual Principal Investigator Worksheet About Local Context (Attachment B41)	Form and Instruction	New	Annual PI Worksheet
225912	Annual signatory Institution Worksheet About Local Context (Attachment B40)	Form and Instruction	New	Annual SI Worksheet
225911	Reviewer Worksheet CPC - Determination of UP or SCN (Attachment B39)	Form and Instruction	New	Reviewer Worksheet CPC UP FB
225910	Reviewer Worksheet of Expedited IR (Attachment B38)	Form and Instruction	New	Reviewer Worksheet ER IR
225909	Reviewer Worksheet expedited Review of Study Chair Response to CIRB-Required Modifications (Attachment B37)	Form and Instruction	New	Reviewer Worksheet SCR ER
225908	Reviewer worksheet Expedited Study Closure Review (Attachment B36)	Form and Instruction	New	reviewer Worksheet ER ClosureWksht
225907	Reviewer Worksheet of Recruitment Material (Attachment B35)	Form and Instruction	New	Reviewer Worksheet Recruitment materials
225906	Reviewer Worksheet of Translated Documents (Attachment B34)	Form and Instruction	New	Reviewer Worksheet Translated Docs
225904	CIRB Application for Translated Documents (Attachment B33)	Form and Instruction	New	CIRB App for Translated Docs
225903	Reviewer worksheet CIRB Statistical Reviewer Form (Attachment B32)	Form and Instruction	New	reviewer Worksheet CIRB Stat
225902	Reviewer Worksheet Determination of UP or SCN (Attachment B31)	Form and Instruction	New	Reviewer Worksheet UP FB
225901	Pediatric Expedited Strudy Chair Response to Required Mod (Attachment B30)	Form and Instruction	New	Ped Exped Chair Resp Req Mods
225900	Adult Expedited Study Chair Response to Required Mod (Attachment B29)	Form and Instruction	New	Adult & CPC Exped Chair Resp Req Mods
225899	Pediatric Cooperative Group Response to CIRB Review (Attachment B28)	Form and Instruction	New	Ped FB SCRWksht
225898	Adult Cooperative Group Response to CIRB Review (Attachment B27)	Form and Instruction	New	Adult & CPC FB SCRWksht
225897	Pediatric Expedited Continuing Review (Attachment B26)	Form and Instruction	New	Ped Expedited CR Worksheet
225895	Adult Expedited Continuing Review (Attachment B25)	Form and Instruction	New	Adult & CPC Expedited CR Worksheet
225894	Pediatric Expedited Amendment Review (Attachment B24)	Form and Instruction	New	Ped Expedited Reviewer Worksheet
225893	Adult Expedited Amendment Review (Attachment B23)	Form and Instruction	New	Adult & CPC Expedited Reviewer Worksheet
225892	CPC Pharmacist's Review of Cooperative Group Study (Attachment B22)	Form and Instruction	New	CPC FB Pharma Reviewer Worksheet
225891	Pharmacist's Review of a Cooperative Group Study (Attachment B21)	Form and Instruction	New	Adult Ped FB Pharma Adult Reviewer Worksheet
225890	Pediatric Amendment of Cooperative Group Protocol (Attachment B20)	Form and Instruction	New	Ped AR FB Reviewer Worksheet
225889	Adult amendment of Cooperative Group Protocol (Attachment B19)	Form and Instruction	New	Adult AR FB Reviewer Worksheet
225888	Pediatric Continuing Review of Cooperative Group Protocol (Attachment B18)	Form and Instruction	New	Oed CR FB Reviewer Worksheet
225887	Adult Continuing Review of Cooperative Group Protocol (Attachment B17)	Form and Instruction	New	Adult CR FB Reviewer Worksheet
225886	Pediatric IR of Cooperative Group Protocol (Attachment B16)	Form and Instruction	New	Ped IR FB Reviewerworksheet
225885	Adult IR of cooperative Group Protocol (Attachment B15)	Form and Instruction	New	Adult IR FB Reviewer Worksheet
225884	CIRB Continuing Review Application (Attachment B14)	Form and Instruction	New	CIRB CR Application
225883	CIRB Ancillary Studies Application (Attachment B13)	Form and Instruction	New	CIRB Ancillary Application
225882	CIRB Amendment Review Application (Attachment B12)	Form and Instruction	New	CIRB AR Application
225881	CIRB IR Application for Exempt Studies (Attachment B11)	Form and Instruction	New	CIRB IR Exempt Application
225880	CIRB IR Application (Attachment B10)	Form and Instruction	New	CIRB IR Application
225879	CIRB COI Screening for CIRB meetings (Attachment B9)	Form and Instruction	New	COI Screening
225878	CIRB Member COI Screening Worksheet (Attachment B8)	Form and Instruction	New	COI Screen
225877	CIRB Direct Deposit Form (Attachment B7)	Form	New	CIRB Direct Deposit Form
225876	CIRB Board Member NDA (Attachment B6)	Form and Instruction	New	CIRB Member NDA
225875	CIRB Board member Contact Information Form (Attachment B4)	Form and Instruction	New	CIRB ContactInfoForm
225874	CIRB Board member Biographical Sketch (Attachment B3)	Form and Instruction	New	CIRB Biosketch Questions CIRB member
225873	NCI CIRB Signatory Enrollment Form (Attachment B2)	Form and Instruction	New	NCI CIRB Signatory Enrollment Form
225871	NCI CIRB AA & DOR between the NCI CIRB and Signatory Institution (Attachment B1)	Form and Instruction	New	NCI CIRB AA DivofResps
225870	CTSU System Access Request Form (Attachment A17)	Form and Instruction	New	System Access Request form
225868	CTSU Transfer Form (Attachment A16)	Form and Instruction	New	Transfer
225866	CTSU Patient Enrollment Transmittal Form (Attachment A15)	Form and Instruction	New	Patient Enrollment Transmittal form
225863	Uncolicited Data Modification Form: Protocol: TAILORx/PACCT-1 (Attachment A14)	Form and Instruction	New	TAILORx UDM
225862	TAILORx_PACCT1_Data Transmittal Form (Attachment A13)	Form and Instruction	New	TAILORx PACCT1_DTF
225861	CTSU Generic Data transmittal form (Attachment A12)	Form and Instruction	New	Generic Data
225860	MC0845 (8233) CTSU Data Transmittal Form (Attachment A11)	Form and Instruction	New	8233 Form
225857	RTOG 0834 CTSU Data Transmittal Form (Attachment A10)	Form and Instruction	New	RTOG0834
225853	Data Clarification Form (Attachment A9)	Form and Instruction	New	Data Clarification Form
225852	Site Initated Data Update Form (Attachment A8)	Form and Instruction	New	Site Data Update form
225850	CTSU Supply Request Form (Attachment A7)	Form and Instruction	New	Supply
225847	CTSU Request for Clinical Brochure (Attachment A6)	Form and Instruction	New	Clinical Brochure
225846	CTSU Roster Update Form (Attachment A5)	Form and Instruction	New	Roster Update
225845	Site Addition Form (Attachment A4)	Form and Instruction	New	Site Addition
225844	Withdrawl from Protocol Participation Form (Attachment A3)	Form and Instruction	New	Withdrawl form
225843	CTSU IRB Certification Form (Attachment A2)	Form and Instruction	New	IRB Certification
225841	CTSU IRB/Regulatory Approval Transmittal Form (Attachment A1)	Form and Instruction	New	IRB Transmittal

ICR Details

OMB Control No: 0925-0753	ICR Reference No: 201702-0925-003
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/NIH	Agency Tracking No:
Title: CTEP Support Contracts Forms and Surveys (NCI)
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 06/01/2017
Retrieve Notice of Action (NOA)	Date Received in OIRA: 03/07/2017
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2020	36 Months From Approved
Responses	100,337	0	0
Time Burden (Hours)	15,524	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: This is a new information collection seeking approval for three years. The National Cancer Institute (NCI) Cancer Therapy Evaluation Program (CTEP) and the Division of Cancer Prevention (DCP) fund an extensive national program of cancer research, sponsoring clinical trials in cancer prevention, symptom management and treatment for qualified clinical investigators. As part of this effort, CTEP and DCP oversee two support programs, the NCI Central Institutional Review Board (CIRB) and the Cancer Trial Support Unit (CTSU). The information collected for both programs is for the purposes of membership, enrollment, opening of Institutional Review Board (IRB) approved studies, documenting IRB review, regulatory approval (for sites not using the CIRB), patient enrollment, and routing of case report forms. Information will also be collected through surveys to assess satisfaction and provide feedback to guide improvements with processes and technology as well as assessing health professional’s interests in clinical trials.

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Authorizing Statute(s): US Code: 42 USC 285a Name of Law: Public Health Service Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 89955	12/13/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 12618	03/06/2017
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 74

table that charts list of burden

IC Title	Form No.	Form Name
Adult Continuing Review of Cooperative Group Protocol (Attachment B17)	33	Adult CR FB Reviewer Worksheet
Adult Cooperative Group Response to CIRB Review (Attachment B27)	43	Adult & CPC FB SCRWksht
Adult Expedited Amendment Review (Attachment B23)	39	Adult & CPC Expedited Reviewer Worksheet
Adult Expedited Continuing Review (Attachment B25)	41	Adult & CPC Expedited CR Worksheet
Adult Expedited Study Chair Response to Required Mod (Attachment B29)	45	Adult & CPC Exped Chair Resp Req Mods
Adult IR of cooperative Group Protocol (Attachment B15)	31	Adult IR FB Reviewer Worksheet
Adult amendment of Cooperative Group Protocol (Attachment B19)	35	Adult AR FB Reviewer Worksheet
Annual Principal Investigator Worksheet About Local Context (Attachment B41)	57	Annual PI Worksheet
Annual signatory Institution Worksheet About Local Context (Attachment B40)	56	Annual SI Worksheet
CIRB Amendment Review Application (Attachment B12)	28	CIRB AR Application
CIRB Ancillary Studies Application (Attachment B13)	29	CIRB Ancillary Application
CIRB Application for Translated Documents (Attachment B33)	49	CIRB App for Translated Docs
CIRB Board Member NDA (Attachment B6)	22	CIRB Member NDA
CIRB Board member Annual Assessment Survey (Attachment C7)	71	Annual CIRB Board Assessment
CIRB Board member Biographical Sketch (Attachment B3)	20	CIRB Biosketch Questions CIRB member
CIRB Board member Contact Information Form (Attachment B4)	21	CIRB ContactInfoForm
CIRB COI Screening for CIRB meetings (Attachment B9)	25	COI Screening
CIRB Continuing Review Application (Attachment B14)	30	CIRB CR Application
CIRB Customer Satisfaction survey (Attachment C4)	65	CIRB Satisfaction survey
CIRB Direct Deposit Form (Attachment B7)	23	CIRB Direct Deposit Form
CIRB IR Application (Attachment B10)	26	CIRB IR Application
CIRB IR Application for Exempt Studies (Attachment B11)	27	CIRB IR Exempt Application
CIRB Member COI Screening Worksheet (Attachment B8)	24	COI Screen
CPC Pharmacist's Review of Cooperative Group Study (Attachment B22)	38	CPC FB Pharma Reviewer Worksheet
CTSU Generic Data transmittal form (Attachment A12)	12	Generic Data
CTSU Help Desk Customer Satisfaction Survey (Attachment C2)	63	Help Desk Survey
CTSU IRB Certification Form (Attachment A2)	2	IRB Certification
CTSU IRB/Regulatory Approval Transmittal Form (Attachment A1)	1	IRB Transmittal
CTSU OPEN Survey (Attachment C3)	64	OPEN survey
CTSU Patient Enrollment Transmittal Form (Attachment A15)	15	Patient Enrollment Transmittal form
CTSU Request for Clinical Brochure (Attachment A6)	6	Clinical Brochure
CTSU Roster Update Form (Attachment A5)	5	Roster Update
CTSU Supply Request Form (Attachment A7)	7	Supply
CTSU System Access Request Form (Attachment A17)	17	System Access Request form
CTSU Transfer Form (Attachment A16)	16	Transfer
CTSU Website Customer Satisfaction Survey (Attachment C1)	62	websurvey final
Change of SI PI Form (Attachment B45)	61	Change PI Worksheet
Concept Clinical Trial Survey (Attachment C9)	73	Concept Survey
Data Clarification Form (Attachment A9)	9	Data Clarification Form
ETCTN PI Survey (Attachment C12)	76	ETCTN PI Survey
ETCTN RS Survey (Attachment C13)	77	ETCTN
Follow-up survey (Communication Audit) (Attachment C5)	66	CIRB FUP Survey
Low Accural clinical Trial Survey (Attachment C11)	75	low accuring survey
MC0845 (8233) CTSU Data Transmittal Form (Attachment A11)	11	8233 Form
NCI CIRB AA & DOR between the NCI CIRB and Signatory Institution (Attachment B1)	18	NCI CIRB AA DivofResps
NCI CIRB Signatory Enrollment Form (Attachment B2)	19	NCI CIRB Signatory Enrollment Form
PIO Customer Satisfaction Survey (Attachment C8)	72	PIO External Survey
Pediatric Amendment of Cooperative Group Protocol (Attachment B20)	36	Ped AR FB Reviewer Worksheet
Pediatric Continuing Review of Cooperative Group Protocol (Attachment B18)	34	Oed CR FB Reviewer Worksheet
Pediatric Cooperative Group Response to CIRB Review (Attachment B28)	44	Ped FB SCRWksht
Pediatric Expedited Amendment Review (Attachment B24)	40	Ped Expedited Reviewer Worksheet
Pediatric Expedited Continuing Review (Attachment B26)	42	Ped Expedited CR Worksheet
Pediatric Expedited Strudy Chair Response to Required Mod (Attachment B30)	46	Ped Exped Chair Resp Req Mods
Pediatric IR of Cooperative Group Protocol (Attachment B16)	32	Ped IR FB Reviewerworksheet
Pharmacist's Review of a Cooperative Group Study (Attachment B21)	37	Adult Ped FB Pharma Adult Reviewer Worksheet
Prospective Clinical Trial Survey (Attachment C10)	74	Prospective Survey
RTOG 0834 CTSU Data Transmittal Form (Attachment A10)	10	RTOG0834
Reviewer Worksheet CPC - Determination of UP or SCN (Attachment B39)	55	Reviewer Worksheet CPC UP FB
Reviewer Worksheet Determination of UP or SCN (Attachment B31)	47	Reviewer Worksheet UP FB
Reviewer Worksheet expedited Review of Study Chair Response to CIRB-Required Modifications (Attachment B37)	53	Reviewer Worksheet SCR ER
Reviewer Worksheet of Expedited IR (Attachment B38)	54	Reviewer Worksheet ER IR
Reviewer Worksheet of Recruitment Material (Attachment B35)	51	Reviewer Worksheet Recruitment materials
Reviewer Worksheet of Translated Documents (Attachment B34)	50	Reviewer Worksheet Translated Docs
Reviewer worksheet CIRB Statistical Reviewer Form (Attachment B32)	48	reviewer Worksheet CIRB Stat
Reviewer worksheet Expedited Study Closure Review (Attachment B36)	52	reviewer Worksheet ER ClosureWksht
Site Addition Form (Attachment A4)	4	Site Addition
Site Initated Data Update Form (Attachment A8)	8	Site Data Update form
Study Closure or Transfer of Study Review Responsibility Form (Attachment B43)	59	Study Closure Worksheet
Study-Specific worksheet About Local Context (Attachment B42)	58	SSW Worksheet
TAILORx_PACCT1_Data Transmittal Form (Attachment A13)	13	TAILORx PACCT1_DTF
UP or SCN Reporting Form (Attachment B44)	60	Unanticipated Problem Worksheet
Uncolicited Data Modification Form: Protocol: TAILORx/PACCT-1 (Attachment A14)	14	TAILORx UDM
Website Focus Groups, Communication Project (Attachments C6 A-D)	69, 70, 67, 68	CIRB Website Focus Group Survey - CIRB Members usability ,   CIRB Website Focus Group Survey - Local Instiutions usability ,   CIRB Website Focus Group Survey - Network Groups usability ,   CIRB Website Focus Group Survey -Web site usability testing
Withdrawl from Protocol Participation Form (Attachment A3)	3	Withdrawl form

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ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	100,337	0	0	100,337	0	0
Annual Time Burden (Hours)	15,524	0	0	15,524	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: New submission

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Annual Cost to Federal Government: $689,035

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 03/07/2017

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