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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
Document Name	Document Type
Att 6_Screen Shots_Data Abstract Elements.pdf Att 6_Data Abstraction Elements (screen shots)	IC Document

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:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.