Information Collection

E-mail Intake form

IC 219416 under ICR 202504-0925-001 · OMB 0925-0208.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 E-mail Intake form	Form
Form 1 Email Intake Form E-mail Intake form	Form
1 Email Intake Form Appendix 2 Email Intake Form on Cancer.gov.docx	Form
1 Email Intake Form Appendix 2 Email Intake Form on Cancer.gov.docx	Form

IC Title:

E-mail Intake form

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

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	1				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: 09-25-0156, âRecords of Participants in Programs and Respondents in Surveys Used to Evaluate Programs of the Public Health Service

FR Citation: 67 FR 67042

Number of Respondents: 9,740

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	9,740	9,740
Annual IC Time Burden (Hours)	1,623	1,623
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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

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