Information Collection

Financial Disclosure Form (Attachments 5A or 5B)

IC 190377 under ICR 201602-0925-006 · OMB 0925-0613.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0613 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 5 Financial Disclosure Form (Attachments 5A or 5B)	Form and Instruction
5 Attach 5 Financial Disclosure Form Attach_5A Financial_disclosure_form_final.pdf	Form and Instruction
6 Attach 5B Financial Disclosure DCP Attach_5B-Financial Disclosure_DCP - Copy.pdf	Form and Instruction

IC Title:

Financial Disclosure Form (Attachments 5A or 5B)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

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
Form and Instruction	5	Attach 5 Financial Disclosure Form	Attach_5A Financial_disclosure_form_final.pdf		Yes	Yes	Fillable Fileable
Form and Instruction	6	Attach 5B Financial Disclosure DCP	Attach_5B-Financial Disclosure_DCP - Copy.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: SORN #09-25-0200, "Clinical, Basic and Population-based Research Studies of the National Institutes of Health (NIH) HHS/NIH/OD"

FR Citation: 67 FR 60776

Number of Respondents: 22,283

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	Previously Approved
Annual Number of Responses for this IC	22,283	1,483	20,800
Annual IC Time Burden (Hours)	1,857	124	1,733
Annual IC Cost Burden (Dollars)	0	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.