Information Collection

Pretest Baseline

IC 181531 under ICR 200708-0920-001 · OMB 0920-0761.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0761 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Pretest Baseline	Form and Instruction
Supplementary Quality of Life Questions Attachment L-SF-12v2 Standard.pdf	Form and Instruction
Pretest Baseline Questionnaire Attachment H Pretest Baseline Questionnaire.doc	Form and Instruction
Attachment D Informed Consent for Pretest.doc Informed Consent for Pretest	IC Document

IC Title:

Pretest Baseline

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

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 and Instruction	None	Supplementary Quality of Life Questions	Attachment L-SF-12v2 Standard.pdf		Yes	Yes	Fillable Printable
Form and Instruction	None	Pretest Baseline Questionnaire	Attachment H Pretest Baseline Questionnaire.doc		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title: 0920-0136 Epidemiologic Studies and Surveillance of Disease Problems

FR Citation: 57 FR 62812

Number of Respondents: 65

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	65	65
Annual IC Time Burden (Hours)	16	16
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Informed Consent for Pretest	Attachment D Informed Consent for Pretest.doc	07/17/2007

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