Information Collection

Aim 2: Emergency Department Patients Consent Form

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

Documents and Forms

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

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Aim 2: Emergency Department Patients Consent Form	Agency IC Tracking Number:

Is this a Common Form? No		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	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 %

	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

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.