Information Collection

CRCCP Clinic-level Information Collection

IC 220791 under ICR 202011-0920-009 · 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⚠️ Notice: This information collection may be referencing outdated material.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
Att 5b - CRCCP Clinic Data Definitions.docx	Instruction
Att 5b - CRCCP Clinic Data Definitions.docx	Instruction
CRCCP Clinic Baseline and Annual Reporting System (CBARS Att 5a - CRCCP Clinic Data Coll Instmt (screenshots) FINAL.docx	Form
CRCCP Clinic Baseline and Annual Reporting System (CBARS Att 5a - CRCCP Clinic Data Coll Instmt (screenshots) FINAL.docx	Form

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	n/a	CRCCP Clinic Baseline and Annual Reporting System (CBARS)	Att 5a - CRCCP Clinic Data Coll Instmt (screenshots) FINAL.docx		Yes	Yes	Fillable Fileable
Instruction			Att 5b - CRCCP Clinic Data Definitions.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 35

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
Annual Number of Responses for this IC	840	840
Annual IC Time Burden (Hours)	700	700
Annual IC Cost Burden (Dollars)	38,279	38,279

Documents for IC

table that charts IC Documents
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.