Information Collection

Healthcare Professionals Screener (Pretest)

IC 235228 under ICR 201903-0910-004 · OMB 0910-0869.

Documents and Forms

Document Name Document Type
Appendix B Screeners Pretest Main.docx Other-Screener
Appendix A Recruitment Materials.docx Appendix A - Recruitment Materials IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Healthcare Professionals Screener (Pretest)	Agency IC Tracking Number:	CDER

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
Other-Screener			Appendix B Screeners Pretest Main.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 63	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	63	63
Annual IC Time Burden (Hours)	5	5
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Appendix A - Recruitment Materials	Appendix A Recruitment Materials.docx	03/07/2019

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