Information Collection

Survey

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

Documents and Forms

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

Information Collection (IC) Details

View Information Collection (IC)

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:

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 %

	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

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.