Information Collection

Self-affirmation and affect

IC 214721 under ICR 201410-0925-004 · OMB 0925-0645.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Self-affirmation and affect	Form and Instruction
1 Survey Screenshots Attachment A Survey ScreenShots.doc	Form and Instruction
0925-0645 Generic Clearance Form 12 9 2014.docx Generic Clearance Form Self-affirmation and affect	IC Document
0925-0645 Justification Memo 12 9 2014.docx Sub-Study Memo Self-affirmation and affect	IC Document
Attachment B Questionaire Word Format.docx Survey- Word Version	IC Document
Attachment C Readings.doc Readings	IC Document
Attachment D IRB Approval.pdf IRB Approval Letter	IC Document

IC Title:

Agency IC Tracking Number:

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 and Instruction	1	Survey Screenshots	Attachment A Survey ScreenShots.doc		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 640

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	640	640
Annual IC Time Burden (Hours)	320	320
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Generic Clearance Form Self-affirmation and affect	0925-0645 Generic Clearance Form 12 9 2014.docx	01/22/2015
Sub-Study Memo Self-affirmation and affect	0925-0645 Justification Memo 12 9 2014.docx	01/22/2015
Survey- Word Version	Attachment B Questionaire Word Format.docx	01/22/2015
Readings	Attachment C Readings.doc	01/22/2015
IRB Approval Letter	Attachment D IRB Approval.pdf	01/22/2015

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