Information Collection

Attach 1o - CTSU Patient Enrollment Transmittal Form

IC 195179 under ICR 201604-0925-004 · OMB 0925-0624.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 15 Attach 1o - CTSU Patient Enrollment Transmittal Form	Form and Instruction
15 CTSU Patient Enrollment Transmittal Form Attachment 1o ENR 61 01 04 e1.pdf	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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
Form and Instruction	15	CTSU Patient Enrollment Transmittal Form	Attachment 1o ENR 61 01 04 e1.pdf		No		Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: Clinical, Basic and Population-based Research Studies of hte National Institutes of Health (NIH), HHS/NIH/OD

FR Citation: 67 FR 60776

Number of Respondents: 200

Number of Respondents for Small Entity: 60

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	2,400	2,400
Annual IC Time Burden (Hours)	400	400
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.