E-mail Intake form

Collection of Customer Service, Demographic and Smoking/Tobacco Use Information from NCI's Contact Center, Cancer Information Service (CIS) Clients (NCI)

OMB: 0925-0208

IC ID: 219416

Information Collection (IC) Details

View Information Collection (IC)

E-mail Intake form
 
No Modified
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form 6 Email Intake Form on Cancer.gov Appendix 2 Email Intake Form on Cancer.gov.docx Yes Yes Fillable Fileable

Health Health Care Services

09-25-0156, “Records of Participants in Programs and Respondents in Surveys Used to Evaluate Programs of the Public Health Service  67 FR 67042

8,796 0
   
Individuals or Households
 
   100 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 8,796 0 7,794 0 0 1,002
Annual IC Time Burden (Hours) 1,466 0 1,299 0 0 167
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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

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