Information Collection

Reference Letter

IC 233551 under ICR 201911-0925-001 · OMB 0925-0758.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 4 Request for Reference iCURE Program Reference Letter	Form
4 Request for Reference iCURE Program Attach4-Request for Reference _ iCURE Program_6222018.pdf	Form
Attach6-Burden Statement.pdf Burden Statement	IC Document

IC Title:

Reference Letter

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

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	4				No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: Clinical Research; Student Records, HHS/PHS/NIH/OD/OIR/OE

FR Citation: 67 FR 60742

Number of Respondents: 240

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	240	240
Annual IC Time Burden (Hours)	120	120
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Burden Statement		10/16/2018

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

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