Information Collection

One Time Study Roll Over Worksheet (Attach 2ZA)

IC 209441 under ICR 201402-0925-001 · OMB 0925-0625.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 2ZA One Time Study Roll Over Worksheet (Attach 2ZA)	Form and Instruction
2ZA One Time Study Roll Over Worksheet REV 2ZA_One Time Study Rollover Worksheet About Local Context_REV.docx	Form and Instruction

IC Title:

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
Form and Instruction	2ZA	One Time Study Roll Over Worksheet REV	2ZA_One Time Study Rollover Worksheet About Local Context_REV.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: 09-25-0200 "Clinical, Basic and Population-based Research Studies of the Natonal Institutes of Health (NIH), HHS/NIH/OD"

FR Citation: 67 FR 60776

Number of Respondents: 120

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	120	120
Annual IC Time Burden (Hours)	20	20
Annual IC Cost Burden (Dollars)	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.