Information Collection

Att 3 Clinic Eligibility Screening Interview

IC 197718 under ICR 201105-0925-003 · OMB 0925-0640.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 2 Att 3 Clinic Eligibility Screening Interview	Form
2 Att 3 Clinic Eligibility Screening Interview Att.3 Clinic Eilgibility Screening Interview.docx	Form

IC Title:

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	2	Att 3 Clinic Eligibility Screening Interview	Att.3 Clinic Eilgibility Screening Interview.docx		No	No	Paper Only

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title: SORN #09-25-200, "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: 742

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	742	742
Annual IC Time Burden (Hours)	124	124
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.