Information Collection

CRCCP Clinic-level Information Collection

IC 220791 under ICR 201705-0920-002 · 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⚠️ Notice: This information collection may be referencing outdated material.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 Att 4a_CRCCP Clinic-Level Data Collection Instrument (screenshots).pdf	Form
Att 4b_CRCCP Clinic Data Dictionary.docx CRCCP Clinic-level Data Dictionary	IC Document
Att 4c_CRCCP Clinic-Level Data 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: Modified

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	Att 4a_CRCCP Clinic-Level Data 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: 30

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	Previously Approved
Annual Number of Responses for this IC	360	-12	372
Annual IC Time Burden (Hours)	192	6	186
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
CRCCP Clinic-level Data Dictionary	Att 4b_CRCCP Clinic Data Dictionary.docx	05/01/2017
Clinic-level collection introductory email	Att 4c_CRCCP Clinic-Level Data Collection Introductory Email.docx	05/01/2017

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