Information Collection

Consent for Bloodspot Retrieval

IC 187391 under ICR 201505-0920-009 · OMB 0920-0010.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0010 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Consent for Bloodspot Retrieval	Form and Instruction
Consent for Bloodspot Release AttM_BloodspotConsent_CLEAN_Jan21_2015.pdf	Form and Instruction
Consent for Bloodspot Retrieval - Spanish AttM2_BloodspotConsent_Spanish.pdf	Form and Instruction
Consent for Bloodspot Retrieval - Multiples AttN_BloodspotConsent_Multiples_Feb23.pdf	Form and Instruction
Consent for Bloodspot Retrieval - Multiples - Spanish AttN2_MultiplesConsent_Spanish.pdf	Form and Instruction

IC Title:

Consent for Bloodspot Retrieval

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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	none	Consent for Bloodspot Release	AttM_BloodspotConsent_CLEAN_Jan21_2015.pdf	Yes	No	Paper Only
Form and Instruction	none	Consent for Bloodspot Retrieval - Spanish	AttM2_BloodspotConsent_Spanish.pdf	Yes	No	Paper Only
Form and Instruction	none	Consent for Bloodspot Retrieval - Multiples	AttN_BloodspotConsent_Multiples_Feb23.pdf	Yes	No	Paper Only
Form and Instruction	none	Consent for Bloodspot Retrieval - Multiples - Spanish	AttN2_MultiplesConsent_Spanish.pdf	Yes	No	Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: 09-20-0136 Epidemiologic Studies and Surveillance of Disease Problems

FR Citation: 57 FR 62812

Number of Respondents: 1,375

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	Previously Approved
Annual Number of Responses for this IC	1,375	-4,400	5,775
Annual IC Time Burden (Hours)	344	-1,100	1,444
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
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.