Information Collection

Completes, Main Study

IC 236802 under ICR 202006-0910-002 · OMB 0910-0875.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
APPENDIX B questionnaire.docx	Other-Survey Instrument
APPENDIX D informed consent.docx	Other-Informed Consent

IC Title:

Agency IC Tracking Number:

CDER

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
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: 566

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	566	566
Annual IC Time Burden (Hours)	187	187
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.