Information Collection

Clinic Staff Instructions: Contact Information and the Consent to be Contacted

IC 188699 under ICR 200904-0920-004 · OMB 0920-0813.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Instructions for Clinic Staff & Consent form Clinic Staff Instructions: Contact Information and the Consent to be Contacted	Form and Instruction
Form 3 Scott and White Consent Form Clinic Staff Instructions: Contact Information and the Consent to be Contacted	Form
Form 2 Contact Information and Consent Form Clinic Staff Instructions: Contact Information and the Consent to be Contacted	Form
1 Instructions for Clinic Staff & Consent form Att 5 Instructions for Clinic Staff Revised 01.28.doc	Form and Instruction
3 Scott and White Consent Form Att 7 Scott and White Consent Form Revised 03 10 09.doc	Form
2 Contact Information and Consent Form Att 6 Contact Information Form.doc	Form
Att 4 Recruitment Flyer.doc Recruitment Flyer	IC Document

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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	1	Instructions for Clinic Staff & Consent form	Att 5 Instructions for Clinic Staff Revised 01.28.doc	No	No	Paper Only
Form	3	Scott and White Consent Form	Att 7 Scott and White Consent Form Revised 03 10 09.doc	No	No	Paper Only
Form	2	Contact Information and Consent Form	Att 6 Contact Information Form.doc	No	No	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 88

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	88	88
Annual IC Time Burden (Hours)	12	12
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Recruitment Flyer	Att 4 Recruitment Flyer.doc	03/20/2009

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