Form 1 Attachment 1 NLM ACA Survey Instrument

OMB Control Number: 0925-XXXX
Expiration Date: XX/XX/XXXX

Public reporting burden for this collection of information is estimated to average 30 minutes per
response, including the time for reviewing instructions, searching exiting data sources, gathering and
maintaining the data needed, and completing and reviewing the collection of information. An agency
may not conduct or sponsor, and a person is not required to respond to, a collection of information
unless it displays a current valid OMB control number. Send comments regarding this burden estimate or
any other aspect of this collection of information, including suggestions for reducing this burden, to NIH,
Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN:PRA
(INSERT CONTROL #). Do not return the completed form to this address.

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