Information Collection

Indepth Inverview Guide and Consent form

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

Documents and Forms

Documents and forms in this information collection
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

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 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 %

table that charts list of burden
	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

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.