Information Collection

Objective 3 Consent Form

IC 210552 under ICR 201402-0925-003 · OMB 0925-0699.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Objective 3 Consent Form	Form
1 Objective 3 consent form Attachment 1B HIV_HBV_Objective_3_Clinical_Followup_Consent_Form_1_2014_V_2.0.docx	Form

IC Title:

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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	1	Objective 3 consent form	Attachment 1B HIV_HBV_Objective_3_Clinical_Followup_Consent_Form_1_2014_V_2.0.docx		No	No	Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 35

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	35	35
Annual IC Time Burden (Hours)	9	9
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.