Wave 1 Survey

[NCCDPHP]Social and Economic Barriers to Receiving Optimal Services Along the Cancer Care Continuum

Documents and Forms

Document Name Document Type
Form 0920-23IE Wave 1 Survey Form
0920-23IE Wave 1 Survivor Survey_English Attachment 2a cover sheet_Wave 1 Survivor Survey_online_English.docx Form
0920-23IE Wave 1 Survivor Survey_Spanish Attachment 2c cover sheet_Wave 1 Survivor Survey_online_Spanish.docx Form
Attachment 2b cover sheet_Wave 1 Survivor Survey_paper_English.docx Wave 1 Survivor Survey_paper_English IC Document
Attachment 2d cover sheet_Wave 1 Survivor Survey_paper_Spanish.docx Wave 1 Survivor Survey_paper_Spanish IC Document
Attachment 2e cover sheet_Wave 1 Survivor Survey consent form.docx Wave 1 Survivor Survey consent form IC Document
Attachment 2f cover sheet_Wave 1 Survivor Survey consent form_Spanish.docx Wave 1 Survivor Survey consent form_Spanish IC Document
Attachment 2g cover sheet_Wave 1 Survivor Survey recruitment communications.docx Wave 1 Survivor Survey recruitment communications IC Document
Attachment 2h cover sheet_Wave 1 Survivor Survey recruitment communications_Spanish.docx Wave 1 Survivor Survey recruitment communications_Spanish IC Document

Information Collection (IC) Details

IC Title:	Wave 1 Survey	Agency IC Tracking Number:	0920-23IE

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	0920-23IE	Wave 1 Survivor Survey_English	Attachment 2a cover sheet_Wave 1 Survivor Survey_online_English.docx		Yes	Yes	Fillable Fileable
Form	0920-23IE	Wave 1 Survivor Survey_Spanish	Attachment 2c cover sheet_Wave 1 Survivor 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: 3,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	3,000	3,000
Annual IC Time Burden (Hours)	1,000	1,000
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Wave 1 Survivor Survey_paper_English	Attachment 2b cover sheet_Wave 1 Survivor Survey_paper_English.docx	09/04/2024
Wave 1 Survivor Survey_paper_Spanish	Attachment 2d cover sheet_Wave 1 Survivor Survey_paper_Spanish.docx	09/04/2024
Wave 1 Survivor Survey consent form	Attachment 2e cover sheet_Wave 1 Survivor Survey consent form.docx	09/04/2024
Wave 1 Survivor Survey consent form_Spanish	Attachment 2f cover sheet_Wave 1 Survivor Survey consent form_Spanish.docx	09/04/2024
Wave 1 Survivor Survey recruitment communications	Attachment 2g cover sheet_Wave 1 Survivor Survey recruitment communications.docx	09/04/2024
Wave 1 Survivor Survey recruitment communications_Spanish	Attachment 2h cover sheet_Wave 1 Survivor Survey recruitment communications_Spanish.docx	09/04/2024

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