Information Collection

Individual specimen collection of blood, urine, and saliva

IC 223493 under ICR 201608-0920-013 · OMB 0920-1137.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1137 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Individual specimen collection of blood, urine, and saliva	Form
Adult Consent Form - English Att E - Adult Consent Form.docx	Form
Adult Consent Form - Spanish Att E - Adult Consent Form SPANISH.docx	Form
Assent Children 5-14 - English Att F - Assent for Children aged 5-14.docx	Form
Assent Children 5-14 - Spanish Att F - Assent for Children aged 5-14 SPANISH.docx	Form

IC Title:

Individual specimen collection of blood, urine, and saliva

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

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?	Electronic Capability
Form	NA	Adult Consent Form - English	Att E - Adult Consent Form.docx	NA	No	Paper Only
Form	NA	Adult Consent Form - Spanish	Att E - Adult Consent Form SPANISH.docx	NA	No	Paper Only
Form	NA	Assent Children 5-14 - English	Att F - Assent for Children aged 5-14.docx	NA	No	Paper Only
Form	NA	Assent Children 5-14 - Spanish	Att F - Assent for Children aged 5-14 SPANISH.docx	NA	No	Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: 09-20-0113 Epidemic Investigation Case Records Systems Notice

FR Citation: 51 FR 42466

Number of Respondents: 500

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	500	500
Annual IC Time Burden (Hours)	83	83
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.