Information Collection

Clinical Exam

IC 210241 under ICR 201401-0925-009 · OMB 0925-0626.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 2 Clinical Exam	Form
Att_15 Clinic Exam Visit Instructions.pdf	Instruction
Att_25 Clinic Exam Saliva Mailing Instructions.pdf	Instruction
Att_24 Clinic Exam Saliva Collection Instructions.pdf	Instruction
1 INFORMED CONSENT FORM Att16 Clinic Exam Informed Consent Booklet.pdf	Form
2 Clinical Exam Saliva Collection Log Att26 Clinic Exam Saliva Collection Log 12052013.pdf	Form
3 Clinical Exam Questioniare Att27 Clinic Exam Questionnaire_12042013.pdf	Form
4 Clinical Exam Mental Health Questionnaire Att28 Clinic Exam Mental Health Questionnaire_12042013.pdf	Form
Att_10 Clinic Exam Invitation Letter.pdf Att_10 Clinic Exam Invitation Letter	IC Document
Att_11 Clinic Exam Scheduling Script.pdf Att_11 Clinic Exam Scheduling Script	IC Document
Att_12 Clinic Exam Visit Confirmation Letter.pdf Att_12 Clinic Exam Visit Confirmation Letter	IC Document
Att_13 Clnic Exam Informed Consent Summary.pdf Att_13 Clnic Exam Informed Consent Summary	IC Document
Att_14 Clinic Exam Frequently Asked Questions.pdf Att_14 Clinic Exam Frequently Asked Questions	IC Document
Att_17 Clinic Exam Blood Pressure Results Form.pdf Att_17 Clinic Exam Blood Pressure Results Form	IC Document
Att_18 Clinic Exam Body Mass Index Results Form.pdf Att_18 Clinic Exam Body Mass Index Results Form	IC Document
Att_19 Clinic Exam Cholesterol Results Form.pdf Att_19 Clinic Exam Cholesterol Results Form	IC Document
Att_20 Clinic Exam Hemoglobin Results Form.pdf Att_20 Clinic Exam Hemoglobin Results Form	IC Document
Att_21 Clinic Exam Heart Rate Results Form.pdf Att_21 Clinic Exam Heart Rate Results Form	IC Document
Att_22 Clinic Exam Pulmonary Function Result Form.pdf Att_22 Clinic Exam Pulmonary Function Result Form	IC Document
Att_23 Clinic Exam Saliva Collection General Instructions.pdf Att_23 Clinic Exam Saliva Collection General Instructions	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Clinical Exam

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	2	Clinical Exam Saliva Collection Log	Att26 Clinic Exam Saliva Collection Log 12052013.pdf	Yes	Yes	Fillable Fileable
Form	3	Clinical Exam Questioniare	Att27 Clinic Exam Questionnaire_12042013.pdf	Yes	Yes	Fillable Fileable
Form	4	Clinical Exam Mental Health Questionnaire	Att28 Clinic Exam Mental Health Questionnaire_12042013.pdf	Yes	Yes	Fillable Fileable
Instruction			Att_15 Clinic Exam Visit Instructions.pdf	No	No	Paper Only
Instruction			Att_25 Clinic Exam Saliva Mailing Instructions.pdf	No	No	Paper Only
Instruction			Att_24 Clinic Exam Saliva Collection Instructions.pdf	No	No	Paper Only
Form	1	INFORMED CONSENT FORM	Att16 Clinic Exam Informed Consent Booklet.pdf	Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: General Science and Innovation

Subfunction: Scientific and Technological Research and Innovation

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 4,000

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	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	4,000	4,000
Annual IC Time Burden (Hours)	16,000	16,000
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Att_10 Clinic Exam Invitation Letter	Att_10 Clinic Exam Invitation Letter.pdf	01/29/2014
Att_11 Clinic Exam Scheduling Script	Att_11 Clinic Exam Scheduling Script.pdf	01/29/2014
Att_12 Clinic Exam Visit Confirmation Letter	Att_12 Clinic Exam Visit Confirmation Letter.pdf	01/29/2014
Att_13 Clnic Exam Informed Consent Summary	Att_13 Clnic Exam Informed Consent Summary.pdf	01/29/2014
Att_14 Clinic Exam Frequently Asked Questions	Att_14 Clinic Exam Frequently Asked Questions.pdf	01/29/2014
Att_17 Clinic Exam Blood Pressure Results Form	Att_17 Clinic Exam Blood Pressure Results Form.pdf	01/29/2014
Att_18 Clinic Exam Body Mass Index Results Form	Att_18 Clinic Exam Body Mass Index Results Form.pdf	01/29/2014
Att_19 Clinic Exam Cholesterol Results Form	Att_19 Clinic Exam Cholesterol Results Form.pdf	01/29/2014
Att_20 Clinic Exam Hemoglobin Results Form	Att_20 Clinic Exam Hemoglobin Results Form.pdf	01/29/2014
Att_21 Clinic Exam Heart Rate Results Form	Att_21 Clinic Exam Heart Rate Results Form.pdf	01/29/2014
Att_22 Clinic Exam Pulmonary Function Result Form	Att_22 Clinic Exam Pulmonary Function Result Form.pdf	01/29/2014
Att_23 Clinic Exam Saliva Collection General Instructions	Att_23 Clinic Exam Saliva Collection General Instructions.pdf	01/29/2014

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