Information Collection

Indepth Inverview Guide and Consent form

IC 188701 under ICR 200904-0920-004 · OMB 0920-0813.

Documents and Forms

Document Name Document Type
Form 5 Indepth Inverview Guide and Consent form Form and Instruction
5 Informed Consent Att 9 Informed Consent Form.doc Form and Instruction
6 In-Depth Interview Guide and Form Att 10 In-depth Interview Guide Revised 01.28.doc Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Indepth Inverview Guide and 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 and Instruction	5	Informed Consent	Att 9 Informed Consent Form.doc		No	No	Paper Only
Form and Instruction	6	In-Depth Interview Guide and Form	Att 10 In-depth Interview Guide Revised 01.28.doc		No	No	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 27	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	27	27
Annual IC Time Burden (Hours)	27	27
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.