Information Collection

Refusal to Consent

IC 44898 under ICR 200909-1910-002 · OMB 1910-5122.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1910-5122 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form DOE F 470.6 Refusal to Consent	Form
DOE F 470.6 Refusal of Consent 470-6[1].pdf	Form

IC Title:

Refusal to Consent

Agency IC Tracking Number:

Felecia Briggs

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 10 CFR 712.15(c)

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	DOE F 470.6	Refusal of Consent	470-6[1].pdf		Yes	No	Printable Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 10,340

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

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	10,340	-1,160	11,500
Annual IC Time Burden (Hours)	6,204	5,054	1,150
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.