MEDICAL RESPONSIBILITY STATEMENT FOR USE OF METHADONE IN A TREATMENT PROGRAM

ICR 198011-0910-006

OMB: 0910-0042

Federal Form Document

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Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
ICR Details
0910-0042 198011-0910-006
Historical Active 198001-0910-002
HHS/FDA
MEDICAL RESPONSIBILITY STATEMENT FOR USE OF METHADONE IN A TREATMENT PROGRAM
Reinstatement with change of a previously approved collection   No
Regular
Approved without change 11/28/1980
Retrieve Notice of Action (NOA) 11/28/1980
  Inventory as of this Action Requested Previously Approved
12/31/1980 12/31/1980
200 0 0
100 0 0
0 0 0

THIS IS AN AGREEMENT SIGNED BY A PHYSICIAN THAT HE UNDERSTANDS AND WILL PERFORM THE MINIMAL REQUIREMENTS OF THE METHADONE REGULATION DURING HIS PARTICIPATION IN THE TREATMENT OF NARCOTIC ADDICTION BY AN APPROVED METHADONE TREATMENT PROGRAM.

None
None


No

1
IC Title Form No. Form Name
MEDICAL RESPONSIBILITY STATEMENT FOR USE OF METHADONE IN A TREATMENT PROGRAM FD 2633

  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 200 0 0 0 200 0
Annual Time Burden (Hours) 100 0 0 0 100 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No

$0
No
No
Uncollected
Uncollected
Uncollected
Uncollected

  No

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
11/28/1980


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