Information Collection

Family Support for Children with Serious Illnesses

IC 214723 under ICR 201202-0925-003 · OMB 0925-0653.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0653 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Family Support for Children with Serious Illnesses	Form
1 Survey Screenshots Appendix A Feedback Instrument.docx	Form
NINR_0925-0653_FastTrackGenericSubStudyClearance_January2015(revised).docx Fast-Track Template	IC Document
Appendix B Outreach Language.docx Invitation Email	IC Document

IC Title:

Family Support for Children with Serious Illnesses

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	1	Survey Screenshots	Appendix A Feedback Instrument.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 100

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 Agency Discretion
Annual Number of Responses for this IC	100	100
Annual IC Time Burden (Hours)	17	17
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Fast-Track Template	NINR_0925-0653_FastTrackGenericSubStudyClearance_January2015(revised).docx	01/22/2015
Invitation Email	Appendix B Outreach Language.docx	01/22/2015

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