Information Collection

Annual NBCCEDP Survey

IC 233706 under ICR 202111-0920-005 · OMB 0920-1046.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1046 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-1046 Annual NBCCEDP Survey	Form and Instruction
0920-1046 Annual National Breast and Cervical Early Detection Prog Att 5 - Annual NBCCEDP Survey.docx	Form and Instruction
0920-1046 Annual National Breast and Cervical Early Detection Prog Att 5 - Annual NBCCEDP Survey.docx	Form and Instruction
Att 5a - Annual NBCCEDP Survey (screenshots).docx NBCCEDP Annual Grantee Survey (Screenshots)	IC Document
Att 5a - Annual NBCCEDP Survey (screenshots).docx NBCCEDP Annual Grantee Survey (Screenshots)	IC Document
Att 5c - Annual NBCCEDP Survey Reminder Email.docx Annual NBCCEDP Survey Reminder E-mail	IC Document
Att 5c - Annual NBCCEDP Survey Reminder Email.docx Annual NBCCEDP Survey Reminder E-mail	IC Document

IC Title:

Annual NBCCEDP Survey

Agency IC Tracking Number:

0920-1046

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 and Instruction	0920-1046	Annual National Breast and Cervical Early Detection Program (NBCCEDP) Survey	Att 5 - Annual NBCCEDP Survey.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 70

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	Previously Approved
Annual Number of Responses for this IC	70	0	70
Annual IC Time Burden (Hours)	65	1	64
Annual IC Cost Burden (Dollars)	2,998	0	2,998

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
NBCCEDP Annual Grantee Survey (Screenshots)	Att 5a - Annual NBCCEDP Survey (screenshots).docx	11/15/2021
Annual NBCCEDP Survey Reminder E-mail	Att 5c - Annual NBCCEDP Survey Reminder Email.docx	11/15/2021

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.