OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

Individuals

IC 195897 under ICR 201407-0925-006 · OMB 0925-0631.

Documents and Forms
Document Name
Document Type
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
IC Document
IC Document
Information Collection (IC) Details

View Information Collection (IC)

Individuals
 
No Removed
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction 1 Telephone Interview Attachment 5 Telephone Interview v5 (2578 - Activated Traditional).pdf Yes Yes Paper Only
Form and Instruction 2 Physical Exam Attachment 8-PhysicalExam v3 (59451- Activated Traditional).pdf Yes Yes Paper Only
Form and Instruction 3 Phone Questionnaire PhoneQuestionnaire v6 (35261 - Traditional).pdf Yes Yes Paper Only

Health Health Care Services

 

1,500 0
   
Individuals or Households
 
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 0 0 1,500 -1,500 0 0
Annual IC Time Burden (Hours) 0 0 701 -701 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Attachment 9 IDEAL_Script - PT Interview Consent Attachment 9 IDEAL_Script - PT Interview Consent.docx 01/27/2011
Attachment 10 Written Informed Consent_IDEAL Home Screening_1-10-11 Attachment 10 Written Informed Consent_IDEAL Home Screening_1-10-11.docx 01/27/2011
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.