Stakeholder Measures and Advocate Forms at the National Cancer Institute (NCI)

Forms and Documents

Document Name	Status
Form 2 Survey Form	New
Form 1 Profile Completion Form and Instruction	New
pub 30day FRN2021-19544.pdf Supplementary Document	2021-09-10
Attachment 4 Privacy Act Memo.pdf Supplementary Document	2021-09-07
Attachment 3 PIA.pdf Supplementary Document	2021-09-07
0925-XXXX - SSA OAR NEW-8-24-2021.docx Supporting Statement A	2021-09-07

IC Document Collections

IC ID	Document Title	Status
249202	Survey Form	New
249201	Profile Completion Form and Instruction	New

ICR Details

OMB Control No:	ICR Reference No: 202109-0925-002
Status: Received in OIRA	Previous ICR Reference No:
Agency/Subagency: HHS/NIH	Agency Tracking No:
Title: Stakeholder Measures and Advocate Forms at the National Cancer Institute (NCI)
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 09/13/2021

	Requested	Previously Approved
Expiration Date	36 Months From Approved
Responses	45	0
Time Burden (Hours)	16	0
Cost Burden (Dollars)	0	0

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Abstract: These forms were submitted under, “Generic Submission for Formative Research, Pre-testing, Stakeholder Measures and Advocate Forms at NCI” (OMB #: 0925-0641, Expiration Date: 1/31/2021). However, since OAR had not submitted Gen ICs under OMB # 0925-0641, it was recommended by OMB that a “regular” submission be done for the current instruments. This information collection request is to approve the Stakeholder Measures and Advocate Forms at NCI for three years. The Office of Advocacy Relations (OAR) disseminates cancer-related information to a variety of stakeholders, seeks input and feedback, and facilitates collaboration to advance NCI’s authorized programs.

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Authorizing Statute(s): US Code: 42 USC sect 410 and sect 285 Name of Law: Public Health Service Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	85 FR 63565	10/08/2020
30-day Notice:	Federal Register Citation:	Citation Date:
	86 FR 50719	09/10/2021
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 2

IC Title	Form No.	Form Name
Profile Completion	1	Profile Completion Questionnaire
Survey	2	Survey

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ICR Summary of Burden

	Total Request	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	45	0	0	45	0	0
Annual Time Burden (Hours)	16	0	0	16	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: new submission

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Annual Cost to Federal Government: $5,567

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 09/13/2021

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