Information Collection

Pilot Study Screener

IC 214499 under ICR 201510-0910-006 · OMB 0910-0785.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
0785 Questionnaire Revised 10-15-2015.docx	Other-Questionnaire

IC Title:

Agency IC Tracking Number:

CDER

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 21 CFR 202.1(e)(5)(i) 21 CFR 202.1(e)(3)(ii) 21 CFR 202.1(e)(6)(i)

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
Other-Questionnaire			0785 Questionnaire Revised 10-15-2015.docx		Yes	Yes	Fillable Fileable Signable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 6,013

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	6,013	6,013
Annual IC Time Burden (Hours)	180	180
Annual IC Cost Burden (Dollars)	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.