Information Collection

Healthcare Study

IC 246366 under ICR 202103-0910-011 · OMB 0910-0896.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Appendix A - Questionnaire.docx	Other-Survey Instrument
Appendix A - Questionnaire.docx	Other-Survey Instrument
Appendix B - Recruitment Script.docx	Other-Recruitment Script
Appendix B - Recruitment Script.docx	Other-Recruitment Script
Appendix D - Drug Names.docx	Other-List of Drug Names
Appendix D - Drug Names.docx	Other-List of Drug Names
Appendix E - Informed Consent.docx	Other-Consent
Appendix E - Informed Consent.docx	Other-Consent

IC Title:

Healthcare Study

Agency IC Tracking Number:

CDER

Is this a Common Form? No

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-Survey Instrument	Appendix A - Questionnaire.docx	Yes	Yes	Fillable Fileable
Other-Recruitment Script	Appendix B - Recruitment Script.docx	Yes	No	Printable Only
Other-List of Drug Names	Appendix D - Drug Names.docx	Yes	No	Printable Only
Other-Consent	Appendix E - Informed Consent.docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 493

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	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	493	493
Annual IC Time Burden (Hours)	163	163
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.