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⚠️ Notice: This information collection may be referencing outdated material.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

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

Information Collection (IC) Details

View Information Collection (IC)

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:

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 %

	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

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.