Information Collection

ACAM2000® Myopericarditis Registry

IC 200540 under ICR 201112-0720-001 · OMB 0720-0054.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
ACAM Registry Survey_Initial.pdf	Other-Survey
ACAM Registry_Follow-up Survey.pdf	Other-Survey
InformedConsentForm.pdf	Other-consent
CaseDef.pdf	Other-null
DD Form 2870 Authorization for Disclosure of Medical or Dental Inform DoD Records Request dd2870[1].pdf	Form

IC Title:

ACAM2000Â® Myopericarditis Registry

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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Survey			ACAM Registry Survey_Initial.pdf	Yes	Yes	Fillable Fileable
Other-Survey			ACAM Registry_Follow-up Survey.pdf	Yes	Yes	Fillable Fileable
Other-consent			InformedConsentForm.pdf	Yes	Yes	Fillable Fileable
Other-null			CaseDef.pdf	Yes	Yes	Fillable Fileable
Form	DD Form 2870	Authorization for Disclosure of Medical or Dental Information	DoD Records Request dd2870[1].pdf	Yes	No	Fillable Printable

Line of Business: Defense and National Security

Subfunction: Operational Defense

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 20

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 50 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	40	40
Annual IC Time Burden (Hours)	20	20
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.