Information Collection

Adult Consent

IC 233851 under ICR 201811-0923-001 · OMB 0923-0059.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0923-0059 can be found here:

Documents and Forms

Document Name Document Type
Adult Consent Form
Adult Consent PrtApndxB2_Adult Consent Form_20190206_clean.docx Form
PrtApndxB1_PrivacyActStatement 20181012.docx Privacy Act Statement IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Adult Consent	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	NA	Adult Consent	PrtApndxB2_Adult Consent Form_20190206_clean.docx	NA	Yes	No	Fillable Fileable Signable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title: Records of Persons Exposed or Potentially Exposed to Toxic or Hazardous Substances	FR Citation: 76 FR 4432

Number of Respondents: 1,501	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,501	1,501
Annual IC Time Burden (Hours)	250	250
Annual IC Cost Burden (Dollars)	6,079	6,079

Documents for IC

Title	Document	Date Uploaded
Privacy Act Statement	PrtApndxB1_PrivacyActStatement 20181012.docx	11/01/2018

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