Information Collection

Consent to Participate- Adult Respondent (Appendix D)

IC 255851 under ICR 202206-2528-002 · OMB 2528-0259.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Final - Appendix D_Consent Form_Adult HoH.docx	Other-Consent to Participate- Adult
Final 1-18-23-Appendix D_Consent Form_Adult HoH.docx	Other-Consent to Participate- Adult

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
Other-Consent to Participate- Adult Respondent (Appendix D)					No		Paper Only

Line of Business: Community and Social Services

Subfunction: Community and Regional Development

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 2,241

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	2,241	2,241
Annual IC Time Burden (Hours)	381	381
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.

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