Web-based Partner Survey

Assessment of the Cancer Survivorship Demonstration Project

Documents and Forms

Document Name Document Type
Web-based Partner Survey Form
Partner Survey Att 3c_ Web-based Partner Survey.docx Form
Partner Survey - screenshots Att 3d_ Screenshots of Web-based Partner Survey.docx Form

Information Collection (IC) Details

IC Title:	Web-based Partner Survey	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

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	Partner Survey	Att 3c_ Web-based Partner Survey.docx		Yes	Yes	Fillable Fileable
Form	none	Partner Survey - screenshots	Att 3d_ Screenshots of Web-based Partner Survey.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 40	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	40	40
Annual IC Time Burden (Hours)	13	13
Annual IC Cost Burden (Dollars)	287	287

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.