Information Collection

Pretest

IC 219544 under ICR 201601-0910-003 · OMB 0910-0818.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Appendix A_Screener and Informed Conset_PretestMain 092515.docx	Other-Appendix A - Screener and Info
Appendix B_Hearing Test and Questionnaire_PretestMain 092515.docx	Other-Appendix B - Hearing Test and

IC Title:

Pretest

Agency IC Tracking Number:

CDER

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

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-Appendix A - Screener and Informed Consent			Appendix A_Screener and Informed Conset_PretestMain 092515.docx		Yes	Yes	Fillable Fileable
Other-Appendix B - Hearing Test and Questionnaire			Appendix B_Hearing Test and Questionnaire_PretestMain 092515.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 640

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	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	640	640
Annual IC Time Burden (Hours)	480	480
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.