Information Collection

Consent and Interview

IC 214247 under ICR 201411-0920-010 · OMB 0920-1058.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1058 can be found here:

Documents and Forms

Document Name Document Type
Consent and Interview Form
Survey Att 4_Survey Screenshots.pdf Form
Att 3_Clinician Interview Invitation.docx Interview Invitation IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Consent and Interview	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

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	none	Survey	Att 4_Survey Screenshots.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 175	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	175	175
Annual IC Time Burden (Hours)	88	88
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Interview Invitation	Att 3_Clinician Interview Invitation.docx	12/15/2014

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