Information Collection

Completes, Pretests Phase 1

IC 215727 under ICR 201503-0910-009 · OMB 0910-0791.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0910-0791 can be found here:

Documents and Forms

Document Name Document Type
CONSUMER SURVEY 3-17-15.docx Other-Consumer Survey
CONSENT FORM CONSUMER 3-17-25.doc Other-Consent Form Consumer
PATIENT EMAIL INVITE 3-17-15.docx Other-Patient Email Invite

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Completes, Pretests Phase 1	Agency IC Tracking Number:	CDER

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Consumer Survey	CONSUMER SURVEY 3-17-15.docx	Yes	Yes	Fillable Fileable Signable
Other-Consent Form Consumer	CONSENT FORM CONSUMER 3-17-25.doc	Yes	Yes	Fillable Fileable Signable
Other-Patient Email Invite	PATIENT EMAIL INVITE 3-17-15.docx	Yes	No	Printable Only

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 400	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	400	400
Annual IC Time Burden (Hours)	200	200
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.