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⚠️ Notice: This information collection may be referencing outdated material.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

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

Information Collection (IC) Details

View Information Collection (IC)

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:

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 %

	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

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.