NBCCEDP Clinic-Level Data Collection Instruments

National Breast and Cervical Cancer Early Detection Program (NBCCEDP) Monitoring Activities

Documents and Forms

Document Name Document Type
Form 0920-1046 NBCCEDP Clinic-Level Data Collection Instruments Form and Instruction
0920-1046 NBCCEDP Clinic-Level Data Collection Instruments Att 6 - NBCCEDP Clinic-Level Data Collection Instruments.docx Form and Instruction
0920-1046 NBCCEDP Clinic-Level Data Collection Instruments Att 6 - NBCCEDP Clinic-Level Data Collection Instruments.docx Form and Instruction
Att 6a - NBCCEDP Clinic Level Data Collection Instruments (screenshots).docx NBCCEDP Clinic-Level Data Instrument (Screenshots) IC Document
Att 6a - NBCCEDP Clinic Level Data Collection Instruments (screenshots).docx NBCCEDP Clinic-Level Data Instrument (Screenshots) IC Document
Att 6b - NBCCEDP Clinic-Level Data Collection Introductory Email.docx NBCCEDP Clinic-Level Data Collection Introductory Email IC Document
Att 6b - NBCCEDP Clinic-Level Data Collection Introductory Email.docx NBCCEDP Clinic-Level Data Collection Introductory Email IC Document
Att 6c - NBCCEDP Clinic-Level Data Collection Reminder Email.docx NBCCEDP Clinic-Level Data Collection Reminder E-mail IC Document
Att 6c - NBCCEDP Clinic-Level Data Collection Reminder Email.docx NBCCEDP Clinic-Level Data Collection Reminder E-mail IC Document

Information Collection (IC) Details

IC Title:	NBCCEDP Clinic-Level Data Collection Instruments	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	NBCCEDP Clinic-Level Data Collection Instruments	Att 6 - NBCCEDP Clinic-Level Data Collection Instruments.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: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	420	0	420
Annual IC Time Burden (Hours)	315	-35	350
Annual IC Cost Burden (Dollars)	17,989	0	17,989

Documents for IC

Title	Document	Date Uploaded
NBCCEDP Clinic-Level Data Instrument (Screenshots)	Att 6a - NBCCEDP Clinic Level Data Collection Instruments (screenshots).docx	11/01/2021
NBCCEDP Clinic-Level Data Collection Introductory Email	Att 6b - NBCCEDP Clinic-Level Data Collection Introductory Email.docx	11/15/2021
NBCCEDP Clinic-Level Data Collection Reminder E-mail	Att 6c - NBCCEDP Clinic-Level Data Collection Reminder Email.docx	11/15/2021

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