Information Collection

An Exploratory Assessment of Substances Used as Adjuncts or Alternatives to Prescription Opioids

IC 243036 under ICR 201910-0910-010 · OMB 0910-0847.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0910-0847 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Attachment A - Screener.docx	Other-Screener
Appendix B - List of Prescription Opioids.docx	Other-List of Prescription Opioids
Appendix C - List of Prescription Benzodiazepines.docx	Other-List of Prescription Benzodiaz
Attachment D - Informed Consent Form.docx	Other-Consent Form
Attachment E - Reminder Language.docx	Other-Reminder
Attachment F - Interview Guide.docx	Other-Interview Guide
Certificate of Confidentiality.pdf	Other-Certificate of Confidentiality
0847 OMB Approval Memo Exploratory Assessment of Substances Used 2020.docx OMB Approval Memo	IC Document

IC Title:

An Exploratory Assessment of Substances Used as Adjuncts or Alternatives to Prescription Opioids

Agency IC Tracking Number:

CDER

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Screener	Attachment A - Screener.docx	Yes	Yes	Fillable Fileable
Other-List of Prescription Opioids	Appendix B - List of Prescription Opioids.docx	Yes	No	Printable Only
Other-List of Prescription Benzodiazepines	Appendix C - List of Prescription Benzodiazepines.docx	Yes	No	Printable Only
Other-Consent Form	Attachment D - Informed Consent Form.docx	Yes	Yes	Fillable Fileable Signable
Other-Reminder	Attachment E - Reminder Language.docx	Yes	No	Printable Only
Other-Interview Guide	Attachment F - Interview Guide.docx	Yes	No	Printable Only
Other-Certificate of Confidentiality	Certificate of Confidentiality.pdf	Yes	No	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 280

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	280	280
Annual IC Time Burden (Hours)	210	210
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
OMB Approval Memo	0847 OMB Approval Memo Exploratory Assessment of Substances Used 2020.docx	08/05/2020

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