UMMC Questionnarie

Information Collection on Soil-transmitted Helminth Infections in Alabama and Mississippi

Documents and Forms

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

Information Collection (IC) Details

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:

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 %

	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

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.