Medical Release and Healthcare Source Forms

Case Investigation of Cervical Cancer (CICC) Study

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.