Information Collection

Attach 1D - Optional Form 1 - Withdrawal from Protocol Participation Form

IC 195156 under ICR 201409-0925-002 · OMB 0925-0624.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0624 can be found here:

Documents and Forms

Document Name Document Type
Form 4 Attach 1D - Optional Form 1 - Withdrawal from Protocol Participation Form Form and Instruction
4 Optional Form 1 - Withdrawal from Protocol Participation attachment_1d_wd.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Attach 1D - Optional Form 1 - Withdrawal from Protocol Participation Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	4	Optional Form 1 - Withdrawal from Protocol Participation	attachment_1d_wd.pdf		Yes	Yes	Fillable Fileable Signable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: Clinical, Basic and Population-based Research Studies of hte National Institutes of Health (NIH), HHS/NIH/OD	FR Citation: 67 FR 60776

Number of Respondents: 50	Number of Respondents for Small Entity: 16

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	600	600
Annual IC Time Burden (Hours)	50	50
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.