Information Collection

Individuals

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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Individuals	Form and Instruction
1 Telephone Interview Attachment 5 Telephone Interview v5 (2578 - Activated Traditional).pdf	Form and Instruction
2 Physical Exam Attachment 8-PhysicalExam v3 (59451- Activated Traditional).pdf	Form and Instruction
3 Phone Questionnaire PhoneQuestionnaire v6 (35261 - Traditional).pdf	Form and Instruction
Attachment 9 IDEAL_Script - PT Interview Consent.docx Attachment 9 IDEAL_Script - PT Interview Consent	IC Document
Attachment 10 Written Informed Consent_IDEAL Home Screening_1-10-11.docx Attachment 10 Written Informed Consent_IDEAL Home Screening_1-10-11	IC Document

IC Title:

Individuals

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Removed

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	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

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,500

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	1,500	-1,500
Annual IC Time Burden (Hours)	701	-701
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.