Information Collection

Sub-Study #15: The Surveillance, Epidemiology, and End Results (SEER) Residual Tissue Repository Program: Survey to Assess Service Delivery and Product Quality

IC 203874 under ICR 201108-0925-002 · OMB 0925-0642.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0642 can be found here:

Documents and Forms

Document Name Document Type
Form 1 Sub-Study #15: The Surveillance, Epidemiology, and End Results (SEER) Residual Tissue Repository Program: Survey to Assess Service Delivery and Product Quality Form and Instruction
1 RTR Survey #15_Attach 3_RTR survey screenshots.pdf Form and Instruction
#15_SEER RTR_Fast-Track_Request_8_17_2012.doc #15_SEER RTR_Fast-Track_Request_8_17_2012 IC Document
#15_Attach 1_RTR survey Word.doc #15_Attach 1_RTR survey Word IC Document
#15_Attach 2_RTR_Invitiation Letter.doc #15_Attach 2_RTR_Invitiation Letter IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Sub-Study #15: The Surveillance, Epidemiology, and End Results (SEER) Residual Tissue Repository Program: Survey to Assess Service Delivery and Product Quality	Agency IC Tracking Number:

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 and Instruction	1	RTR Survey	#15_Attach 3_RTR survey screenshots.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 72	Number of Respondents for Small Entity: 9

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to New Statute	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA	Previously Approved
Annual Number of Responses for this IC	72	0	0	0	0	0
Annual IC Time Burden (Hours)	6	0	0	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
#15_SEER RTR_Fast-Track_Request_8_17_2012	#15_SEER RTR_Fast-Track_Request_8_17_2012.doc	08/20/2012
#15_Attach 1_RTR survey Word	#15_Attach 1_RTR survey Word.doc	08/20/2012
#15_Attach 2_RTR_Invitiation Letter	#15_Attach 2_RTR_Invitiation Letter.doc	08/20/2012

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