Information Collection

Verbal Consent [Participants of Patient-level Intervention]

IC 249764 under ICR 202109-0920-005 · OMB 0920-1361.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Verbal Consent [Participants of Patient-level Intervention]	Form and Instruction
Verbal Consent [Participants] Att 8a_Verbal consent_participants.docx	Form and Instruction
Verbal Consent [Participants] Att 8a_Verbal consent_participants.docx	Form and Instruction

IC Title:

Agency IC Tracking Number:

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	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	n/a	Verbal Consent [Participants]	Att 8a_Verbal consent_participants.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

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

FR Citation: 57 FR 62812

Number of Respondents: 153

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	153	153
Annual IC Time Burden (Hours)	38	38
Annual IC Cost Burden (Dollars)	832	832

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.