Information Collection

Completes, Pretests Phase 1

IC 215727 under ICR 201510-0910-007 · OMB 0910-0791.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Consumer Questionnaire Revised 0791 10-14-2015.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

IC Title:

Agency IC Tracking Number:

CDER

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	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Consumer Survey	Consumer Questionnaire Revised 0791 10-14-2015.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 %

table that charts list of burden
	Approved	Previously Approved
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

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.