Phase I - Screener

Experimental Study of Patient Information Prototypes

Documents and Forms

Document Name Document Type
Quantitative Questionnaire.doc Other-Quantitative Questionnaire
Formative guide - 06-23-11.doc Other-Formative Guide

Information Collection (IC) Details

IC Title:	Phase I - Screener	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation: 21 CFR 208 21 CFR 310.501.21 21 CFR 310.515

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Quantitative Questionnaire			Quantitative Questionnaire.doc		Yes	No	Fillable Printable
Other-Formative Guide			Formative guide - 06-23-11.doc		No		Fillable Printable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 400	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	400	400
Annual IC Time Burden (Hours)	13	13
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.