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⚠️ Notice: This information collection may be referencing outdated material.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

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

Information Collection (IC) Details

View Information Collection (IC)

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:

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 %

	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

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.