Survior Interview Guide

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

Documents and Forms

Document Name Document Type
Form 0920-23IE Survior Interview Guide Form
0920-23IE Survivor Interview Guide Attachment 5a cover sheet_Survivor Interview Guide.docx Form
Attachment 7b cover sheet_Patient and Survivor Advo Org Focus Group consent form.docx Focus Group consent form IC Document
Attachment 7c cover sheet_Patient and Survivor Advo Org Focus Group recruitment communications.docx Focus Group recruitment communications IC Document

Information Collection (IC) Details

IC Title:	Survior Interview Guide	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	Survivor Interview Guide	Attachment 5a cover sheet_Survivor Interview Guide.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 20	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	20	20
Annual IC Time Burden (Hours)	20	20
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Focus Group consent form	Attachment 7b cover sheet_Patient and Survivor Advo Org Focus Group consent form.docx	09/05/2024
Focus Group recruitment communications	Attachment 7c cover sheet_Patient and Survivor Advo Org Focus Group recruitment communications.docx	09/05/2024

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