Information Collection

NBCCEDP Clinic-Level Data Instrument (Cervical)

IC 233708 under ICR 202501-0920-002 · OMB 0920-1046.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-1046 NBCCEDP Clinic-Level Data Instrument (Cervical)	Form and Instruction
Form 0920-1046 NBCCEDP Clinic-Level Data Collection Instruments (Cervical) NBCCEDP Clinic-Level Data Instrument (Cervical)	Form and Instruction
0920-1046 NBCCEDP Clinic-Level Data Collection Instruments (Cervic Att 6 - NBCCEDP Clinic-Level Data Collection Instruments.docx	Form and Instruction
0920-1046 NBCCEDP Clinic-Level Data Collection Instruments (Cervic Att 6 - NBCCEDP Clinic-Level Data Collection Instruments.docx	Form and Instruction
Att 6a - NBCCEDP Clinic-Level Data Collection Instruments (screenshots).docx NBCCEDP Clinic-Level Data Instrument (Screenshots)	IC Document
Att 6a - NBCCEDP Clinic-Level Data Collection Instruments (screenshots).docx NBCCEDP Clinic-Level Data Instrument (Screenshots)	IC Document

IC Title:

Agency IC Tracking Number:

0920-1046

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	0920-1046				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 71

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	426	6	420
Annual IC Time Burden (Hours)	284	-31	315
Annual IC Cost Burden (Dollars)	0	-17,989	17,989

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
NBCCEDP Clinic-Level Data Instrument (Screenshots)		01/08/2025

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

Something went wrong when downloading this file. If you have any questions, please send an email to [email protected].