Information Collection

Phase 1 Consent

IC 218948 under ICR 202103-0920-007 · OMB 0920-1100.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1100 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Att 10a_Phase 1 Consent form (English).docx	Other-Consent Form (English)
Att 10a_Phase 1 Consent form (English).docx	Other-Consent Form (English)
Att 10b_Phase 1 Consent Form (Spanish).docx	Other-Consent Form (Spanish)
Att 10b_Phase 1 Consent Form (Spanish).docx	Other-Consent Form (Spanish)

IC Title:

Phase 1 Consent

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
Other-Consent Form (English)			Att 10a_Phase 1 Consent form (English).docx		No		Paper Only
Other-Consent Form (Spanish)			Att 10b_Phase 1 Consent Form (Spanish).docx		No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 2,334

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	2,334	2,334
Annual IC Time Burden (Hours)	584	584
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.