Information Collection

Screener, Pretest and Main Study: Consumers and Primary Care Physicians

IC 259758 under ICR 202304-0910-006 · OMB 0910-0916.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Appendix A - Questionnaire FINAL.docx	Other-Questionnaire
Appendix A - Questionnaire FINAL.docx	Other-Questionnaire
SSB Med Tracking FINAL.docx	Other-Screener
SSB Med Tracking FINAL.docx	Other-Screener
Appendix C - Informed Consent FINAL.docx	Other-Informed consent
Appendix C - Informed Consent FINAL.docx	Other-Informed consent

IC Title:

Agency IC Tracking Number:

CDER

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	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Questionnaire	Appendix A - Questionnaire FINAL.docx	Yes	Yes	Fillable Fileable
Other-Screener	SSB Med Tracking FINAL.docx	Yes	Yes	Fillable Fileable
Other-Informed consent	Appendix C - Informed Consent FINAL.docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,360

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	1,360	1,360
Annual IC Time Burden (Hours)	373	373
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.