Patient Eligibility Screener

[NCCDPHP] Evaluation of a Prostate Cancer Decision Aid

Documents and Forms

Document Name Document Type
Form 0920-24CB Patient Eligibility Screener Form
Form 0920-24CB Patient Eligibility Screener Form
0920-24CB Patient Eligibility Screener_English Attachment 06a_Pre-Exposure Survey_Eligibility Screener_English.docx Form
0920-24CB Patient Eligibility Screener_English Attachment 06a_Pre-Exposure Survey_Eligibility Screener_English.docx Form
0920-24CB Patient Eligibility Screener_Spanish Attachment 06b_Pre-Exposure Survey_Eligibility Screener_Spanish.docx Form
0920-24CB Patient Eligibility Screener_Spanish Attachment 06b_Pre-Exposure Survey_Eligibility Screener_Spanish.docx Form
Attachment 06c_Pre-Exposure Survey_Consent Statement_English.docx Consent Statement_English IC Document
Attachment 06c_Pre-Exposure Survey_Consent Statement_English.docx Consent Statement_English IC Document
Attachment 06d_Pre-Exposure Survey_Consent Statement_Spanish.docx Consent Statement_Spanish IC Document
Attachment 06d_Pre-Exposure Survey_Consent Statement_Spanish.docx Consent Statement_Spanish IC Document

Information Collection (IC) Details

IC Title:	Patient Eligibility Screener	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	Patient Eligibility Screener_English	Attachment 06a_Pre-Exposure Survey_Eligibility Screener_English.docx		Yes	Yes	Fillable Fileable
Form	0920-24CB	Patient Eligibility Screener_Spanish	Attachment 06b_Pre-Exposure Survey_Eligibility Screener_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: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	900	900
Annual IC Time Burden (Hours)	120	120
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Consent Statement_English	Attachment 06c_Pre-Exposure Survey_Consent Statement_English.docx	08/05/2024
Consent Statement_Spanish	Attachment 06d_Pre-Exposure Survey_Consent Statement_Spanish.docx	08/05/2024

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