VA Cooperative Study Project #500A, National Registry of Veterans with Amyotrophic Lateral Sclerosis (ALS)

Documents and Forms

Document Name Document Type
Form VA Form 10-21047a VA Cooperative Study Project #500A, National Registry of Veterans with Amyotrophic Lateral Sclerosis (ALS) Form
VA Form 10-21047 ALS Registry Screening Form 10-21047 ALS REGISTRY SCREENING FORM.doc Form
VA Form 10-21047a Biannual Telephone Interview, National Registry of Veter 10-21047a Biannual Telephone Interview.doc Form
VA Form 10-21074b Verbal Informed Consent VIA Telephone, Nataional Registr 10-21047b Verbal Consent via Telephone.doc Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	VA Cooperative Study Project #500A, National Registry of Veterans with Amyotrophic Lateral Sclerosis (ALS)	Agency IC Tracking Number:	2900-0649

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Electronic Capability
Form	VA Form 10-21047a	Biannual Telephone Interview, National Registry of Veterans with ALS	10-21047a Biannual Telephone Interview.doc	No	Paper Only
Form	VA Form 10-21074b	Verbal Informed Consent VIA Telephone, Nataional Registry of Veterans with ALS	10-21047b Verbal Consent via Telephone.doc	No	Paper Only
Form	VA Form 10-21047	ALS Registry Screening Form	10-21047 ALS REGISTRY SCREENING FORM.doc	No	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,808	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	1,808	-932	2,740
Annual IC Time Burden (Hours)	882	-414	1,296
Annual IC Cost Burden (Dollars)	0	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.