Information Collection

Consent and Interview

IC 214247 under ICR 201605-0920-002 · OMB 0920-1058.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Consent and Interview	Form
Survey 0920-1058 screenshots_April2016.pdf	Form
Att 3_Clinician Interview Invitation.docx Interview Invitation	IC Document

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	none	Survey	0920-1058 screenshots_April2016.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 200

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Not-for-profit institutions

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	200	25	175
Annual IC Time Burden (Hours)	100	12	88
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Interview Invitation	Att 3_Clinician Interview Invitation.docx	12/15/2014

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.