Information Collection

Consent Form

IC 216378 under ICR 201504-0920-010 · OMB 0920-1080.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1080 can be found here:

Documents and Forms

Document Name Document Type
Att 6_Screen Shots_Data Abstract Elements.pdf Att 6_Data Abstraction Elements (screen shots) IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Consent Form	Agency IC Tracking Number:	15JX

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation: 3 CFR 301.241(a)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 450	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	450	450
Annual IC Time Burden (Hours)	113	113
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Att 6_Data Abstraction Elements (screen shots)	Att 6_Screen Shots_Data Abstract Elements.pdf	05/15/2015

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