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				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		03/27/2014

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

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