Att 6_Informed Consent Form

Project NICE: Navigating Insurance Coverage Expansion

Documents and Forms

Document Name Document Type
Form 0920- Att 6_Informed Consent Form Form
0920- Informed Consent Form Att 6 Informed Consent Form 17AUZ FINAL 051818.docx Form

Information Collection (IC) Details

IC Title:	Att 6_Informed Consent Form	Agency IC Tracking Number:	0920-17AUZ

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	0920-	Informed Consent Form	Att 6 Informed Consent Form 17AUZ FINAL 051818.docx		Yes	Yes	Fillable Fileable Signable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title: 09-20-0136 Epidemiologic Studies and Surveillance of Disease Problems	FR Citation: 57 FR 62812

Number of Respondents: 1,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,000	1,000
Annual IC Time Burden (Hours)	167	167
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.