Post-exposure survey

[NCCDPHP] Evaluation of a Prostate Cancer Decision Aid

Documents and Forms

Document Name Document Type
Form 0920-24CB Post-exposure survey Form
Form 0920-24CB Post-exposure survey Form
0920-24CB Post Exposure Survey _English Attachment 07f_Post-Exposure Survey_Online_English.docx Form
0920-24CB Post Exposure Survey _Spanish Attachment 07g_Post-Exposure Survey_Online_Spanish.docx Form
Attachment 07a_Post-Exposure Survey_Assigned Materials and Survey Link_English.docx Post-Exposure Survey_Assigned Materials and Survey Link_English IC Document
Attachment 07b_Post-Exposure Survey_Assigned Materials and Survey Link_Spanish.docx Post-Exposure Survey_Assigned Materials and Survey Link_Spanish IC Document
Attachment 07d_Post-Exposure Survey_Consent Statement_Spanish.docx Post-Exposure Survey_Consent Statement_Spanish IC Document
Attachment 07c_Post-Exposure Survey_Consent Statement_English.docx Post-Exposure Survey_Consent Statement_English IC Document
Attachment 07h_Post-Exposure Survey_Reminder Email_English.docx Post-Exposure Survey_Reminder Email_English IC Document
Attachment 07i_Post-Exposure Survey_Reminder Email_Spanish.docx Post-Exposure Survey_Reminder Email_Spanish IC Document

Information Collection (IC) Details

IC Title:	Post-exposure survey	Agency IC Tracking Number:	0920-24CB

Is this a Common Form? No		IC Status: New

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	0920-24CB	Post Exposure Survey _English	Attachment 07f_Post-Exposure Survey_Online_English.docx		Yes	Yes	Fillable Fileable
Form	0920-24CB	Post Exposure Survey _Spanish	Attachment 07g_Post-Exposure Survey_Online_Spanish.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 900	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	900	900
Annual IC Time Burden (Hours)	300	300
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Post-Exposure Survey_Assigned Materials and Survey Link_English	Attachment 07a_Post-Exposure Survey_Assigned Materials and Survey Link_English.docx	08/02/2024
Post-Exposure Survey_Assigned Materials and Survey Link_Spanish	Attachment 07b_Post-Exposure Survey_Assigned Materials and Survey Link_Spanish.docx	08/02/2024
Post-Exposure Survey_Consent Statement_Spanish	Attachment 07d_Post-Exposure Survey_Consent Statement_Spanish.docx	08/02/2024
Post-Exposure Survey_Consent Statement_English	Attachment 07c_Post-Exposure Survey_Consent Statement_English.docx	08/02/2024
Post-Exposure Survey_Reminder Email_English	Attachment 07h_Post-Exposure Survey_Reminder Email_English.docx	08/02/2024
Post-Exposure Survey_Reminder Email_Spanish	Attachment 07i_Post-Exposure Survey_Reminder Email_Spanish.docx	08/02/2024

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