Information Collection

Phase 1: Screener Completes (assumes 30% eligible)

IC 243688 under ICR 202201-0910-008 · OMB 0910-0895.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Phase 1 Screener - HCP.pdf	Other-Screener - HCP
Phase 1 Screener - HCP.pdf	Other-Screener - HCP

IC Title:

Agency IC Tracking Number:

CDER

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-Screener - HCP			Phase 1 Screener - HCP.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 104

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	104	104
Annual IC Time Burden (Hours)	9	9
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.