Information Collection

Reference Letter

IC 233551 under ICR 201810-0925-004 · OMB 0925-0758.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0758 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 4 Reference Letter	Form
4 Request for Reference iCURE Program Attach4-Request for Reference _ iCURE Program_6222018.pdf	Form
Attach6-Burden Statement.pdf Burden Statement	IC Document

IC Title:

Reference Letter

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	4	Request for Reference iCURE Program	Attach4-Request for Reference _ iCURE Program_6222018.pdf		No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: Clinical Research; Student Records, HHS/PHS/NIH/OD/OIR/OE

FR Citation: 67 FR 60742

Number of Respondents: 240

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	240	240
Annual IC Time Burden (Hours)	120	120
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Burden Statement	Attach6-Burden Statement.pdf	10/16/2018

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.