Information Collection

Attach 1D - Optional Form 1 - Withdrawal from Protocol Participation Form

IC 195156 under ICR 201011-0925-002 · OMB 0925-0624.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0624 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 4 Attach 1D - Optional Form 1 - Withdrawal from Protocol Participation Form	Form and Instruction
4 Attach 1D - Optional Form 1 - Withdrawal from Protocol P attach_1d_wthdrw.pdf www.ctsu.org/CTSU_Optional_Form1_Final.pdf	Form and Instruction

IC Title:

Attach 1D - Optional Form 1 - Withdrawal from Protocol Participation Form

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
Form and Instruction	4	Attach 1D - Optional Form 1 - Withdrawal from Protocol Participation Form	attach_1d_wthdrw.pdf	https://www.ctsu.org/CTSU_Optional_Form1_Final.pdf	Yes	Yes	Fillable Fileable Signable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: Clinical, Basic and Population-based Research Studies of hte National Institutes of Health (NIH), HHS/NIH/OD

FR Citation: 67 FR 60776

Number of Respondents: 50

Number of Respondents for Small Entity: 16

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 50 %

table that charts list of burden
	Approved	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	600	600
Annual IC Time Burden (Hours)	50	50
Annual IC Cost Burden (Dollars)	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.