Information Collection

Phase 2 Consent

IC 218949 under ICR 202112-0920-002 · OMB 0920-1100.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-1100 Phase 2 Consent	Form
0920-1100 Att 11a_Phase 2 Consent form (English) Att 11a_Phase 2 Consent form (English).docx	Form
0920-1100 Att 11a_Phase 2 Consent form (English) Att 11a_Phase 2 Consent form (English).docx	Form
0920-1100 Att 8b_Phase 2 Behavioral Survey (Spanish) Att 8b_Phase 2 Behavioral Survey (Spanish).docx	Form
0920-1100 Att 8b_Phase 2 Behavioral Survey (Spanish) Att 8b_Phase 2 Behavioral Survey (Spanish).docx	Form

IC Title:

Phase 2 Consent

Agency IC Tracking Number:

0920-1100

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	0920-1100	Att 11a_Phase 2 Consent form (English)	Att 11a_Phase 2 Consent form (English).docx		Yes	Yes	Fillable Fileable
Form	0920-1100	Att 8b_Phase 2 Behavioral Survey (Spanish)	Att 8b_Phase 2 Behavioral Survey (Spanish).docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 50

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	50	50
Annual IC Time Burden (Hours)	13	13
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.