Information Collection

Objective 3 Consent Form

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

Documents and Forms

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

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Objective 3 Consent Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection 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 %

	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

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.