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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
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

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:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.