Information Collection

Institutional Certification Template

IC 234076 under ICR 202104-0925-002 · OMB 0925-0744.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0744 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 3 Institutional Certification Template	Form and Instruction
3 Institutional Certification Template 0925-0744_DASH_Attach-ment A.2-3_Institutional Certification Template (1).docx	Form and Instruction
3 Institutional Certification Template 0925-0744_DASH_Attach-ment A.2-3_Institutional Certification Template (1).docx	Form and Instruction

IC Title:

Institutional Certification Template

Agency IC Tracking Number:

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
Form and Instruction	3	Institutional Certification Template	0925-0744_DASH_Attach-ment A.2-3_Institutional Certification Template (1).docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: Clinical, Basic and Population-based Research Studies of the National Institutes of Health (NIH), HHS/NIH/OD

FR Citation: 67 FR 60742

Number of Respondents: 36

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	36	36
Annual IC Time Burden (Hours)	3	3
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.