Medical Release and Healthcare Source Forms

Case Investigation of Cervical Cancer (CICC) Study

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1162 can be found here:

Documents and Forms

Document Name Document Type
Medical Release and Healthcare Source Forms Form
Medical Release and Healthcare Source Form - English Attachment 7a. Medical Release and Healthcare Source Forms English 2016 06 10.docx Form
Medical Release and Healthcare Source Form - Spanish Attachment 7b. Medical Release and Healthcare Source Forms Spanish.docx Form

Information Collection (IC) Details

IC Title:	Medical Release and Healthcare Source Forms	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	none	Medical Release and Healthcare Source Form - English	Attachment 7a. Medical Release and Healthcare Source Forms English 2016 06 10.docx		No		Paper Only
Form	none	Medical Release and Healthcare Source Form - Spanish	Attachment 7b. Medical Release and Healthcare Source Forms Spanish.docx		No		Paper Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 334	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	334	334
Annual IC Time Burden (Hours)	28	28
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.