Information Collection

E-mail Intake form

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

Documents and Forms

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

Information Collection (IC) Details

View Information Collection (IC)

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:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	1	Email Intake Form	Appendix 2 Email Intake Form on Cancer.gov.docx		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 %

	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

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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