Information Collection

Consent Form

IC 223141 under ICR 201608-0925-003 · OMB unassigned.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 2 Consent Form	Form
2 Informed Consent ATTACHMENT 15A - Informed Consent_Edited_2_23_16-English.doc	Form
3 Informed Consent SPANISH ATTACHMENT 15B - Informed Consent_Edited_2_23_16_SPANISH.doc	Form

IC Title:

Consent Form

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?	Can Be Submitted Electronically?	Electronic Capability
Form	2	Informed Consent	ATTACHMENT 15A - Informed Consent_Edited_2_23_16-English.doc		No		Paper Only
Form	3	Informed Consent SPANISH	ATTACHMENT 15B - Informed Consent_Edited_2_23_16_SPANISH.doc		No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: Records of Participants in Programs and Respondents in Surveys Used to Evaluate Programs of the Public Health Service

FR Citation: 67 FR 60743

Number of Respondents: 210

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	210	210
Annual IC Time Burden (Hours)	35	35
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.