Information Collection

Sub-study #5_Patient Perspectives and Simulated Clinical Interactions

IC 208125 under ICR 201111-0925-003 · OMB 0925-0645.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0645 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Sub-study #5_Patient Perspectives and Simulated Clinical Interactions	Form and Instruction
1 Simulated Clinical Interaction Survey Attach5B_Questionniare_Screenshots.pdf	Form and Instruction
Sub-Study #5_Justif Memo_Doctor_Interaction_7-22-2013.doc Sub-Study #5_Justif Memo_Doctor_Interaction_7-22-2013	IC Document
Attach5A DoctorScript.doc Attach5A DoctorScript	IC Document
Attach5C Key Readings.docx Attach5C Key Readings	IC Document
Attach5D Consent Form.docx Attach5D Consent Form	IC Document
Attach5E IRB Review.pdf Attach5E IRB Review	IC Document

IC Title:

Sub-study #5_Patient Perspectives and Simulated Clinical Interactions

Agency IC Tracking Number:

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 and Instruction	1	Simulated Clinical Interaction Survey	Attach5B_Questionniare_Screenshots.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 700

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to New Statute	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA	Previously Approved
Annual Number of Responses for this IC	700	0	0	0	0	0
Annual IC Time Burden (Hours)	350	0	0	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Sub-Study #5_Justif Memo_Doctor_Interaction_7-22-2013	Sub-Study #5_Justif Memo_Doctor_Interaction_7-22-2013.doc	07/22/2013
Attach5A DoctorScript	Attach5A DoctorScript.doc	07/22/2013
Attach5C Key Readings	Attach5C Key Readings.docx	07/22/2013
Attach5D Consent Form	Attach5D Consent Form.docx	07/22/2013
Attach5E IRB Review	Attach5E IRB Review.pdf	07/22/2013

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