Information Collection

Consent and Screener: Adults (Ages 26+)

IC 233738 under ICR 201810-0910-014 · OMB 0910-0873.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
4. Expressed Claims Screener.docx	Other-Expressed Claims Screener
5. Expressed Claims Informed Consent.docx	Other-Expressed Claims Informed Cons

IC Title:

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
Other-Expressed Claims Screener			4. Expressed Claims Screener.docx		Yes	Yes	Fillable Fileable Signable
Other-Expressed Claims Informed Consent			5. Expressed Claims Informed Consent.docx		Yes	Yes	Fillable Fileable Signable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 16,500

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	16,500	16,500
Annual IC Time Burden (Hours)	1,650	1,650
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.