Information Collection

CRCCP Clinic-level Information Collection

IC 220791 under ICR 202602-0920-008 · OMB 0920-1074.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-1074 CRCCP Clinic Data Collection Instrument CRCCP Clinic-level Information Collection	Form
Form 0920-1074 Colorectal Cancer Control Program (CRCCP) Clinic Data Dictionary CRCCP Clinic-level Information Collection	Form and Instruction
0920-1074 CRCCP Clinic Data Collection Instrument Attachment 5a - CRCCP Clinic Data Collection Instrument (screenshots).docx	Form
0920-1074 Colorectal Cancer Control Program (CRCCP) Clinic Data Di Attachment 1 - CRCCP DP25 Clinic Data Dictionary_v2026_clean.docx	Form and Instruction
Attachment 5b - CRCCP Clinic Data Dictionary.docx Attachment 5b - CRCCP Clinic Data Dictionary	IC Document
Attachment 5c - CRCCP Clinic-Level Data Collection Introductory Email.docx Attachment 5c - CRCCP Clinic-Level Data Collection Introductory Email	IC Document

IC Title:

Agency IC Tracking Number:

0920-1074

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	0920-1074				Yes	Yes	Fillable Fileable
Form and Instruction	0920-1074			NA	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 35

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	840	840
Annual IC Time Burden (Hours)	700	700
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachment 5b - CRCCP Clinic Data Dictionary		05/07/2024
Attachment 5c - CRCCP Clinic-Level Data Collection Introductory Email		05/07/2024

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

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