Information Collection

PART A, ATTACH A_CHP Screener, Baseline, and Topical Questionnaires_v2

IC 260052 under ICR 202310-0607-007 · OMB 0607-1025.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0607-1025 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Part A, Attachment PART A, ATTACH A_CHP Screener, Baseline, and Topical Questionnaires_v2	Form
Part A, Attachment Part A, Attachment A_CHP Topical 2 and 3 Questionnaire_v Part A, Attachment A_CHP Topical 2 and 3 Questionnaire_v3.docx	Form
Part A, Attachment Part A, Attachment A_CHP Topical 2 and 3 Questionnaire Part A, Attachment A_CHP Topical 2 and 3 Questionnaire_v5.docx	Form

IC Title:

PART A, ATTACH A_CHP Screener, Baseline, and Topical Questionnaires_v2

Agency IC Tracking Number:

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	Part A, Attachment A_CHP Topical 2 and 3	Part A, Attachment A_CHP Topical 2 and 3 Questionnaire	Part A, Attachment A_CHP Topical 2 and 3 Questionnaire_v5.docx		Yes	Yes	Fillable Fileable

Line of Business: General Science and Innovation

Subfunction: Scientific and Technological Research and Innovation

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 132,000

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	Previously Approved
Annual Number of Responses for this IC	132,000	-85,500	217,500
Annual IC Time Burden (Hours)	43,956	-28,472	72,428
Annual IC Cost Burden (Dollars)	0	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.