Information Collection

Informed Consent

IC 216378 under ICR 202305-0920-009 · OMB 0920-1080.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Att 4_HOPS Informed Consent Forms.pdf	Other-Consent for HOPS Data Abstract
Att 4_HOPS Informed Consent Forms.pdf	Other-Consent for HOPS Data Abstract
Att 6_Screen Shots_data abstraction_OpenClinica.pdf Data Items Abstracted from the Participant's Medical Chart by Study Personnel	IC Document
Att 6_Screen Shots_data abstraction_OpenClinica.pdf Data Items Abstracted from the Participant's Medical Chart by Study Personnel	IC Document

IC Title:

Informed Consent

Agency IC Tracking Number:

0920-1080

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
Other-Consent for HOPS Data Abstraction from Medical Chart			Att 4_HOPS Informed Consent Forms.pdf		No		Paper Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title: 09-20-0160 Records of Subjects in Health Promotion and Education Studies

FR Citation: 83 FR 6591

Number of Respondents: 450

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	Previously Approved
Annual Number of Responses for this IC	450	450
Annual IC Time Burden (Hours)	113	113
Annual IC Cost Burden (Dollars)	2,894	2,894

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Data Items Abstracted from the Participant's Medical Chart by Study Personnel	Att 6_Screen Shots_data abstraction_OpenClinica.pdf	05/23/2023

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.