Information Collection

Pilot Study Screener

IC 214499 under ICR 201501-0910-003 · OMB 0910-0785.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0910-0785 can be found here:

Documents and Forms

Document Name Document Type
QUESTIONNAIRE 12-16-14.doc Other-Questionnaire

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Pilot Study Screener	Agency IC Tracking Number:	CDER

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation: 21 CFR 202.1(e)(5)(i) 21 CFR 202.1(e)(3)(ii) 21 CFR 202.1(e)(6)(i)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Questionnaire			QUESTIONNAIRE 12-16-14.doc		Yes	Yes	Fillable Fileable Signable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 6,013	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	6,013	6,013
Annual IC Time Burden (Hours)	180	180
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.