Information Collection

Pretest Screener

IC 214029 under ICR 201510-0910-008 · OMB 0910-0784.

Documents and Forms

Document Name Document Type
SCREENER DOCUMENT 2-26-2015.docx Other-Screener document
EMAIL INVITATION 10-28-14.doc Other-Email Invitation
INFORMED CONSENT FORM 10-28-14.doc Other-Consent Form
SCALE DEVELOPMENT 30 DAY FRN 10-28-14.doc Scale Development IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Pretest Screener	Agency IC Tracking Number:	CDER

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Screener document	SCREENER DOCUMENT 2-26-2015.docx	Yes	Yes	Printable Only
Other-Email Invitation	EMAIL INVITATION 10-28-14.doc	Yes	Yes	Printable Only
Other-Consent Form	INFORMED CONSENT FORM 10-28-14.doc	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 3,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	3,000	1,000	2,000
Annual IC Time Burden (Hours)	99	39	60
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Scale Development	SCALE DEVELOPMENT 30 DAY FRN 10-28-14.doc	11/25/2014

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