Information Collection

Defferal Questionnaire

IC 193150 under ICR 201006-0925-002 · OMB 0925-0620.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Deferral Study Consent Form Portuguese.doc	Other- Deferral Study Consent Form P
Deferral study Questionnaire Portuguese.rtf	Other- Deferral study Questionnaire
Attachment 7_Deferral Informed consent.doc Attachment 7_Deferral Informed consent	IC Document

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
Other- Deferral Study Consent Form Portuguese			Deferral Study Consent Form Portuguese.doc		Yes	Yes	Paper Only
Other- Deferral study Questionnaire Portuguese			Deferral study Questionnaire Portuguese.rtf		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 4,860

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	4,860	4,860
Annual IC Time Burden (Hours)	1,604	1,604
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachment 7_Deferral Informed consent	Attachment 7_Deferral Informed consent.doc	02/25/2010

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.