Information Collection

Survey 2 Claimant Consent Form

IC 212658 under ICR 201604-0925-003 · OMB 0925-0704.

Documents and Forms

Document Name Document Type
Form 7 Survey 2 Claimant Consent Form Form and Instruction
7 Survey 2 Claimant Consent Form Attachment 3_Claimant IRB Approved Consent Form.doc Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Survey 2 Claimant Consent Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

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	7	Survey 2 Claimant Consent Form	Attachment 3_Claimant IRB Approved Consent Form.doc		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

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	Previously Approved
Annual Number of Responses for this IC	3,000	3,000
Annual IC Time Burden (Hours)	750	750
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.