Screener

Survey of Health Care Practitioners for Device Labeling Format and Content

Documents and Forms

Document Name Document Type
Attachment A--Initial Contact Letter with Screener.doc Other-Contact Letter with Screener
Attachment B--Consent Form In Person.doc Other-Consent Form
Attachment C--Follow-Up Letter.doc Other-Follow up letter

Information Collection (IC) Details

IC Title:	Screener	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Instrument File	Available Electronically?	Electronic Capability
Other-Contact Letter with Screener	Attachment A--Initial Contact Letter with Screener.doc	No	Printable Only
Other-Consent Form	Attachment B--Consent Form In Person.doc	No	Printable Only
Other-Follow up letter	Attachment C--Follow-Up Letter.doc	No	Printable Only

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 60	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	60	60
Annual IC Time Burden (Hours)	5	5
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.