Information Collection

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

IC 28925 under ICR 200907-2900-008 · OMB 2900-0649.

Documents and Forms

Documents and forms in this information collection
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

IC Title:

Agency IC Tracking Number:

2900-0649

Is this a Common Form? No

IC Status: Modified

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?	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 %

table that charts list of burden
	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

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.