Federal Cervical Cancer Collaborative (FCCC) Post-Roundtable Evaluation

Voluntary Partner Surveys to Implement Executive Order 12862 in the Health Resources and Services Administration

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0212 can be found here:

Documents and Forms

Document Name Document Type
Form 1 Federal Cervical Cancer Collaborative (FCCC) Post-Roundtable Evaluation Form and Instruction
Form 1 Federal Cervical Cancer Collaborative (FCCC) Post-Roundtable Evaluation Form and Instruction
1 Post-Roundtable-Survey_V02-Final.pdf Moonshot_OMB-Review_Post-Roundtable-Survey_V02-Final.pdf Form and Instruction
1 Post-Roundtable-Survey_V02-Final.pdf Moonshot_OMB-Review_Post-Roundtable-Survey_V02-Final.pdf Form and Instruction
FINAL Supporting Statement A.docx Supporting Statement A IC Document
FINAL Supporting Statement A.docx Supporting Statement A IC Document

Information Collection (IC) Details

IC Title:	Federal Cervical Cancer Collaborative (FCCC) Post-Roundtable Evaluation	Agency IC Tracking Number:

IC Status: Unchanged

Obligation to Respond: Voluntary

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	1	Post-Roundtable-Survey_V02-Final.pdf	Moonshot_OMB-Review_Post-Roundtable-Survey_V02-Final.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 200	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Previously Approved
Annual Number of Responses for this IC	200	200
Annual IC Time Burden (Hours)	17	17
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Supporting Statement A	FINAL Supporting Statement A.docx	03/09/2022

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