Information Collection

ACASI Questionnaire Informed Consent

IC 218844 under ICR 201511-0925-001 · OMB 0925-0726.

Documents and Forms

Document Name Document Type
Form 1 ACASI Questionnaire Informed Consent Form and Instruction
1 Attachment 2 ACASI Questionnaire Informed Consent Attach_2_ACASI_Questionnaire_Informed Consent_1_2015_V_10.0.docx Form and Instruction
3 Attachment 6 ACASI Questionnaire Informed Consent PORTUG Attach_6_ACASI Questionnaire_Informed Consent _PORTUGUESE_Jan_2015_V_6.0.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	ACASI Questionnaire Informed Consent	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	1	Attachment 2 ACASI Questionnaire Informed Consent	Attach_2_ACASI_Questionnaire_Informed Consent_1_2015_V_10.0.docx		Yes	Yes	Fillable Fileable
Form and Instruction	3	Attachment 6 ACASI Questionnaire Informed Consent PORTUGUESE	Attach_6_ACASI Questionnaire_Informed Consent _PORTUGUESE_Jan_2015_V_6.0.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 275	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	275	275
Annual IC Time Burden (Hours)	46	46
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.