Information Collection

Completes, Pretest

IC 236801 under ICR 201907-0910-005 · OMB 0910-0875.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0910-0875 can be found here:

Documents and Forms

Document Name Document Type
APPENDIX B questionnaire.docx Other-Survey Instrument
APPENDIX D informed consent.docx Other-Informed Consent

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Completes, 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-Survey Instrument			APPENDIX B questionnaire.docx		Yes	Yes	Fillable Fileable
Other-Informed Consent			APPENDIX D informed consent.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 158	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	158	158
Annual IC Time Burden (Hours)	53	53
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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