Information Collection

Refusal Questionnaire

IC 194466 under ICR 201008-0925-005 · OMB 0925-0623.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0623 can be found here:

Documents and Forms

Document Name Document Type
Form 5 Refusal Questionnaire Form and Instruction
5 Refusal Questionnaire Attach 21 - Refusal questionnaire.doc Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Refusal Questionnaire	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	5	Refusal Questionnaire	Attach 21 - Refusal questionnaire.doc		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title: Clinical, Basic and Population-based Research Studies of the National Institutes of Health (NIH), HHS/NIH/OD	FR Citation: 67 FR 60776

Number of Respondents: 225	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	225	225
Annual IC Time Burden (Hours)	8	8
Annual IC Cost Burden (Dollars)	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.