Information Collection

Survey of Chronic Gastrointestinal Illness inPersian Gulf Veterans (Irritaable Bowel syndrome - Diarrhea)

IC 188135 under ICR 201209-2900-003 · OMB 2900-0742.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form VA Form 10-21092c Survey of Chronic Gastrointestinal Illness inPersian Gulf Veterans (Irritaable Bowel syndrome - Diarrhea)	Form and Instruction
VA Form 10-21092c Survey of Chronic Gastrointestinal Illness in Persian Gu IBS PG Veterans' Survey.pdf To Be Determined	Form and Instruction
VA Form 10-21092A Patient Consent Form - Cases Study VA Form 10-21092a (Case).doc	Form and Instruction
VA Form 10-21092B Patient Consent Form - Controls Study VA Form 10-21092b (Control).doc	Form and Instruction

IC Title:

Agency IC Tracking Number:

2900-0742

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
Form and Instruction	VA Form 10-21092c	Survey of Chronic Gastrointestinal Illness in Persian Gulf Veterans	IBS PG Veterans' Survey.pdf	To Be Determined	Yes	No	Fillable Printable
Form and Instruction	VA Form 10-21092A	Patient Consent Form - Cases Study	VA Form 10-21092a (Case).doc		No		Paper Only
Form and Instruction	VA Form 10-21092B	Patient Consent Form - Controls Study	VA Form 10-21092b (Control).doc		No		Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: Veteran, Patient, Employee and Volunteer Research and Development Project Records-VA (34VA12)

FR Citation: 45 FR 160

Number of Respondents: 4,354

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	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	4,354	354	4,000
Annual IC Time Burden (Hours)	3,072	0	3,072
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
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.