Information Collection

CRCCP Clinic-level Information Collection

IC 220791 under ICR 202404-0920-011 · OMB 0920-1074.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1074 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-1074 CRCCP Clinic-level Information Collection	Form
0920-1074 CRCCP Clinic Data Collection Instrument Attachment 5a - CRCCP Clinic Data Collection Instrument (screenshots).docx	Form
0920-1074 CRCCP Clinic Data Collection Instrument Attachment 5a - CRCCP Clinic Data Collection Instrument (screenshots).docx	Form
Attachment 5b - CRCCP Clinic Data Dictionary.docx Attachment 5b - CRCCP Clinic Data Dictionary	IC Document
Attachment 5b - CRCCP Clinic Data Dictionary.docx Attachment 5b - CRCCP Clinic Data Dictionary	IC Document
Attachment 5c - CRCCP Clinic-Level Data Collection Introductory Email.docx Attachment 5c - CRCCP Clinic-Level Data Collection Introductory Email	IC Document
Attachment 5c - CRCCP Clinic-Level Data Collection Introductory Email.docx Attachment 5c - CRCCP Clinic-Level Data Collection Introductory Email	IC Document

IC Title:

CRCCP Clinic-level Information Collection

Agency IC Tracking Number:

0920-1074

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	0920-1074	CRCCP Clinic Data Collection Instrument	Attachment 5a - CRCCP Clinic Data Collection Instrument (screenshots).docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 35

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
Annual Number of Responses for this IC	840	840
Annual IC Time Burden (Hours)	700	700
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachment 5b - CRCCP Clinic Data Dictionary	Attachment 5b - CRCCP Clinic Data Dictionary.docx	05/07/2024
Attachment 5c - CRCCP Clinic-Level Data Collection Introductory Email	Attachment 5c - CRCCP Clinic-Level Data Collection Introductory Email.docx	05/07/2024

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