Information Collection

Number to Complete the Survey (85%) - Study 2

IC 220730 under ICR 201804-0910-011 · OMB 0910-0821.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Appendix A - CONSENT FORM.doc	Other-Consent Form
Appendix D - SCREENER.doc	Other-Screener
Appendix C - STUDY 2 QUESTIONNAIRE.doc	Other-Survey

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	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Survey	Appendix C - STUDY 2 QUESTIONNAIRE.doc	Yes	Yes	Fillable Fileable
Other-Consent Form	Appendix A - CONSENT FORM.doc	Yes	Yes	Fillable Fileable
Other-Screener	Appendix D - SCREENER.doc	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 900

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	900	900
Annual IC Time Burden (Hours)	297	297
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.