Information Collection

UMMC Questionnarie

IC 236769 under ICR 201906-0920-008 · OMB 0920-1271.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
UMMC Questionnarie	Form
UMMC Questionnaire Attachment D. UMMC Questionnaire_FINAL_OMB edits (OMB)_AS 09232019.docx	Form
Part of D. IRB Approved ASSENT approved05.21.19 expires 05.19.20.pdf Assent	IC Document
Part of D.IRB Approved PERMISSION TO PARTICIPATE CONSENT approved 05.21.19 expires 05.19.20.pdf Consent	IC Document

IC Title:

UMMC Questionnarie

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	none	UMMC Questionnaire	Attachment D. UMMC Questionnaire_FINAL_OMB edits (OMB)_AS 09232019.docx		Yes	No	Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 358

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	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	358	358
Annual IC Time Burden (Hours)	60	60
Annual IC Cost Burden (Dollars)	432	432

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Assent	Part of D. IRB Approved ASSENT approved05.21.19 expires 05.19.20.pdf	10/07/2019
Consent	Part of D.IRB Approved PERMISSION TO PARTICIPATE CONSENT approved 05.21.19 expires 05.19.20.pdf	10/07/2019

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