Information Collection

Clinical Research Participants

IC 197342 under ICR 201401-0925-006 · OMB 0925-0458.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Clinical Research Participants	Form
1 Patient Survey 3rd Party Patient Survey.NIH Clinical Center.docx	Form
3rd Party Study Mini-Supporting Statement - Clinical Center.docx 3rd Party Study Mini-Supporting Statement - Clinical Center	IC Document
3rd Party Study Generic Clearance Form (2).docx 3rd Party Study Generic Clearance Form (2)	IC Document
3rd Party Study Mini-Supporting Statement REVISED - Clinical Center (2).docx 3rd Party Study Mini-Supporting Statement REVISED - Clinical Center (2)	IC Document

IC Title:

Agency IC Tracking Number:

IC Status: Unchanged

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	Patient Survey	3rd Party Patient Survey.NIH Clinical Center.docx		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 378

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	378	378
Annual IC Time Burden (Hours)	38	38
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
3rd Party Study Mini-Supporting Statement - Clinical Center	3rd Party Study Mini-Supporting Statement - Clinical Center.docx	04/13/2011
3rd Party Study Generic Clearance Form (2)	3rd Party Study Generic Clearance Form (2).docx	04/13/2011
3rd Party Study Mini-Supporting Statement REVISED - Clinical Center (2)	3rd Party Study Mini-Supporting Statement REVISED - Clinical Center (2).docx	04/21/2011

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