Information Collection

Aim 2: Emergency Department Patients Consent Form

IC 183378 under ICR 200801-0920-007 · OMB 0920-0777.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form No number Aim 2: Emergency Department Patients Consent Form	Form
No number Attachment 9 - Aim 2 Emergency Department Consent Form Lindsley influenza OMB Attach 9 Aim 2 ED Patient Consent form.doc	Form

IC Title:

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	No number	Attachment 9 - Aim 2 Emergency Department Consent Form	Lindsley influenza OMB Attach 9 Aim 2 ED Patient Consent form.doc		Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title: Occupational Health Epidemiological Studies

FR Citation: 51 FR 42449

Number of Respondents: 15

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	15	15
Annual IC Time Burden (Hours)	5	5
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.