Information Collection

Discussions on 50+ Donors

IC 226490 under ICR 201502-0915-002 · OMB 0915-0212.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0212 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 2 Discussions on 50+ Donors	Form and Instruction
2 20170303 Attachment 2__FG_Informed Consent (ES) CLEAN Rd 20170303 Attachment 2__FG_Informed Consent (ES) CLEAN Rd 2.docx	Form and Instruction
3 20170303 Attachment 2__FG_Informed Consent (ES) CLEAN Rd 20170303 Attachment 2__FG_Informed Consent (ES) CLEAN Rd 2.docx	Form and Instruction
5 20170303 Attachment 5__FocusGroup_ParticipantScreener (E 20170303 Attachment 5__FocusGroup_ParticipantScreener (EP_DoT) CLEAN.docx	Form and Instruction
6 20170303 Attachment 6__Survey _Screener Questionnaire - 20170303 Attachment 6__Survey _Screener Questionnaire - Rd 2 CLEAN Rd 2.docx	Form and Instruction
20170303 Attachment 1__SupportingStatement_50+ (EP) RA edit.docx Supporting Statement	IC Document

IC Title:

Discussions on 50+ Donors

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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	2	20170303 Attachment 2__FG_Informed Consent (ES) CLEAN Rd 2.docx	20170303 Attachment 2__FG_Informed Consent (ES) CLEAN Rd 2.docx	No		Paper Only
Form and Instruction	3	20170303 Attachment 2__FG_Informed Consent (ES) CLEAN Rd 2.docx	20170303 Attachment 2__FG_Informed Consent (ES) CLEAN Rd 2.docx	No		Paper Only
Form and Instruction	5	20170303 Attachment 5__FocusGroup_ParticipantScreener (EP_DoT) CLEAN.docx	20170303 Attachment 5__FocusGroup_ParticipantScreener (EP_DoT) CLEAN.docx	No		Paper Only
Form and Instruction	6	20170303 Attachment 6__Survey _Screener Questionnaire - Rd 2 CLEAN Rd 2.docx	20170303 Attachment 6__Survey _Screener Questionnaire - Rd 2 CLEAN Rd 2.docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 124

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 25 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	124	124
Annual IC Time Burden (Hours)	71	71
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Supporting Statement	20170303 Attachment 1__SupportingStatement_50+ (EP) RA edit.docx	04/20/2017

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