Information Collection

ACAM2000® Myopericarditis Registry

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

Documents and Forms

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

Information Collection (IC) Details

View Information Collection (IC)

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:

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 %

	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

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.