Form 1 NB Tissue Access Request Form

OMB Control Number: 0925-0667
Expiration Date: XX/XX/XXXX

Public reporting burden for this collection of information is estimated to vary from 30 minutes
per response, including the time for reviewing instructions, searching existing data sources, gathering
and maintaining the data needed, and completing and reviewing the collection of information. An
agency may not conduct or sponsor, and a person is not required to respond to, a collection of
information unless it displays a currently valid OMB control number. Send comments regarding this
burden estimate or any other aspect of this collection of information, including suggestions for reducing
this burden, to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 208927974, ATTN: PRA (0925-0667). Do not return the completed form to this address.

Federal Wide Assurance Number: