Information Collection

In-depth Interview Consent

IC 211018 under ICR 201403-0920-017 · OMB 0920-1018.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Consent In-depth Interview Consent	Form
Consent Consent_screenshot.docx	Form
Att 4c In-depth Interview consent.docx Interview Consent Word Version	IC Document

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	none	Consent	Consent_screenshot.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 30

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	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	30	30
Annual IC Time Burden (Hours)	5	5
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Interview Consent Word Version	Att 4c In-depth Interview consent.docx	03/27/2014

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