Information Collection

Survey

IC 202088 under ICR 201207-0990-006 · OMB 0990-0399.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
EIVRI Instrument After First Round Cuts.pdf	Other-EVRI Survey Instrument and Con
0990-EIVRI_consentAppendix C.docx 0990-EIVRI_consentAppendix C	IC Document

IC Title:

Survey

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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
Other-EVRI Survey Instrument and Consent (Revised)			EIVRI Instrument After First Round Cuts.pdf		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 6,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	6,000	6,000
Annual IC Time Burden (Hours)	2,100	2,100
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
0990-EIVRI_consentAppendix C	0990-EIVRI_consentAppendix C.docx	04/19/2012

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