Information Collection

Individuals

IC 195897 under ICR 201102-0925-003 · OMB 0925-0631.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0631 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Individuals	Form and Instruction
1 Telephone Interview Attachment 5 Telephone Interview v5 (2578 - Activated Traditional).pdf	Form and Instruction
2 Physical Exam Attachment 8-PhysicalExam v3 (59451- Activated Traditional).pdf	Form and Instruction
3 Phone Questionnaire PhoneQuestionnaire v6 (35261 - Traditional).pdf	Form and Instruction
Attachment 9 IDEAL_Script - PT Interview Consent.docx Attachment 9 IDEAL_Script - PT Interview Consent	IC Document
Attachment 10 Written Informed Consent_IDEAL Home Screening_1-10-11.docx Attachment 10 Written Informed Consent_IDEAL Home Screening_1-10-11	IC Document

IC Title:

Individuals

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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	1	Telephone Interview	Attachment 5 Telephone Interview v5 (2578 - Activated Traditional).pdf	Yes	Yes	Paper Only
Form and Instruction	2	Physical Exam	Attachment 8-PhysicalExam v3 (59451- Activated Traditional).pdf	Yes	Yes	Paper Only
Form and Instruction	3	Phone Questionnaire	PhoneQuestionnaire v6 (35261 - Traditional).pdf	Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,500

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	1,500	1,500
Annual IC Time Burden (Hours)	701	701
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachment 9 IDEAL_Script - PT Interview Consent	Attachment 9 IDEAL_Script - PT Interview Consent.docx	01/27/2011
Attachment 10 Written Informed Consent_IDEAL Home Screening_1-10-11	Attachment 10 Written Informed Consent_IDEAL Home Screening_1-10-11.docx	01/27/2011

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