CRCCP Clinic-level Information Collection

Colorectal Cancer Control Program (CRCCP) Monitoring Activities

Documents and Forms

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

Information Collection (IC) Details

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:

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 %

	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

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.