Information Collection

Refusal Questionnaire

IC 194466 under ICR 201012-0925-005 · OMB 0925-0623.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 5 Refusal Questionnaire	Form and Instruction
5 Refusal Questionnaire Attach 21 - Refusal questionnaire.doc	Form and Instruction

IC Title:

Agency IC Tracking Number:

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	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 %

table that charts list of burden
	Approved	Change Due to Potential Violation of the PRA
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

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.