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⚠️ Notice: This information collection may be referencing outdated material.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

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

Information Collection (IC) Details

View Information Collection (IC)

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:

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 %

	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

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.