Information Collection

ABC Screener (Attachment 2)

IC 208639 under ICR 201405-0925-002 · OMB 0925-0684.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 ABC Screener (Attachment 2)	Form and Instruction
1 ABC Screener Attach2_ABC Screener_2-11-2014.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	1	ABC Screener	Attach2_ABC Screener_2-11-2014.docx		No		Paper Only

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title: Clinical, Basic and Population-based Research Studies of hte National Institutes of Health (NIH)

FR Citation: 67 FR 60776

Number of Respondents: 14,000

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	Previously Approved
Annual Number of Responses for this IC	14,000	6,000	8,000
Annual IC Time Burden (Hours)	1,167	500	667
Annual IC Cost Burden (Dollars)	0	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.