Information Collection

Informed Consent

IC 216378 under ICR 202011-0920-013 · OMB 0920-1080.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1080 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Att 4_HOPS Informed Consent Forms.docx	Other-Consent for HOPS Data Abstract
Att 4_HOPS Informed Consent Forms.docx	Other-Consent for HOPS Data Abstract
Att 6_Screen Shots_data abstraction_OpenClinica.pdf Data Items Abstracted from the Participant's Medical Chart by Study Personnel	IC Document
Att 6_Screen Shots_data abstraction_OpenClinica.pdf Data Items Abstracted from the Participant's Medical Chart by Study Personnel	IC Document

IC Title:

Informed Consent

Agency IC Tracking Number:

0920-1080

Is this a Common Form? No

IC Status: Modified

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-Consent for HOPS Data Abstraction from Medical Chart			Att 4_HOPS Informed Consent Forms.docx		No		Paper Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title: 09-20-0160 Records of Subjects in Health Promotion and Education Studies

FR Citation: 83 FR 6591

Number of Respondents: 450

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	Previously Approved
Annual Number of Responses for this IC	450	0	450
Annual IC Time Burden (Hours)	113	0	113
Annual IC Cost Burden (Dollars)	2,894	2,894	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Data Items Abstracted from the Participant's Medical Chart by Study Personnel	Att 6_Screen Shots_data abstraction_OpenClinica.pdf	12/21/2020

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