Information Collection

Consent for Bloodspot Retrieval

IC 187391 under ICR 202101-0920-008 · OMB 0920-0010.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0010 can be found here:

2025-05-01 - No material or nonsubstantive change to a currently approved collection
2024-05-07 - No material or nonsubstantive change to a currently approved collection

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Consent for Bloodspot Retrieval	Form and Instruction
Bloodspot Consent (English) AttR1_BloodspotConsent.docx	Form and Instruction
Bloodspot Consent (English) AttR1_BloodspotConsent.docx	Form and Instruction
Bloodspot Verbal Consent (English) AttS1_BloodspotVerbalConsent.docx	Form and Instruction
Bloodspot Verbal Consent (English) AttS1_BloodspotVerbalConsent.docx	Form and Instruction
Bloodspot Consent for Multiples (English) AttT1_BloodspotConsent_Multiples.docx	Form and Instruction
Bloodspot Consent for Multiples (English) AttT1_BloodspotConsent_Multiples.docx	Form and Instruction
Bloodspot Verbal Consent for Multiples (English) AttU1_BloodspotVerbalConsent_Multiples.docx	Form and Instruction
Bloodspot Verbal Consent for Multiples (English) AttU1_BloodspotVerbalConsent_Multiples.docx	Form and Instruction
Bloodspot Consent (Spanish) AttR2_BloodspotConsent_SPAN.docx	Form and Instruction
Bloodspot Consent (Spanish) AttR2_BloodspotConsent_SPAN.docx	Form and Instruction
Bloodspot Verbal Consent (Spanish) AttS2_BloodspotVerbalConsent_SPAN.docx	Form and Instruction
Bloodspot Verbal Consent (Spanish) AttS2_BloodspotVerbalConsent_SPAN.docx	Form and Instruction
Bloodspot Consent for Multiples (Spanish) AttT2_BloodspotConsent_Multiples_SPAN.docx	Form and Instruction
Bloodspot Consent for Multiples (Spanish) AttT2_BloodspotConsent_Multiples_SPAN.docx	Form and Instruction
Bloodspot Verbal Consent for Multiples (Spanish) AttU2_BloodspotVerbalConsent_Multiples_SPAN.docx	Form and Instruction
Bloodspot Verbal Consent for Multiples (Spanish) AttU2_BloodspotVerbalConsent_Multiples_SPAN.docx	Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Consent for Bloodspot Retrieval

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	Available Electronically?	Electronic Capability
Form and Instruction	n/a	Bloodspot Consent (English)	AttR1_BloodspotConsent.docx	No	Paper Only
Form and Instruction	n/a	Bloodspot Verbal Consent (English)	AttS1_BloodspotVerbalConsent.docx	No	Paper Only
Form and Instruction	n/a	Bloodspot Consent for Multiples (English)	AttT1_BloodspotConsent_Multiples.docx	No	Paper Only
Form and Instruction	n/a	Bloodspot Verbal Consent for Multiples (English)	AttU1_BloodspotVerbalConsent_Multiples.docx	No	Paper Only
Form and Instruction	n/a	Bloodspot Consent (Spanish)	AttR2_BloodspotConsent_SPAN.docx	No	Paper Only
Form and Instruction	n/a	Bloodspot Verbal Consent (Spanish)	AttS2_BloodspotVerbalConsent_SPAN.docx	No	Paper Only
Form and Instruction	n/a	Bloodspot Consent for Multiples (Spanish)	AttT2_BloodspotConsent_Multiples_SPAN.docx	No	Paper Only
Form and Instruction	n/a	Bloodspot Verbal Consent for Multiples (Spanish)	AttU2_BloodspotVerbalConsent_Multiples_SPAN.docx	No	Paper Only

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: 09-20-0136 Epidemiologic Studies and Surveillance of Disease Problems

FR Citation: 57 FR 62812

Number of Respondents: 1,850

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	Previously Approved
Annual Number of Responses for this IC	1,850	1,850
Annual IC Time Burden (Hours)	463	463
Annual IC Cost Burden (Dollars)	4,625	4,625

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.