Information Collection

Study Consent and Contact Information

IC 244204 under ICR 202310-0920-003 · OMB 0920-1333.

Documents and Forms

Document Name Document Type
Study Consent and Contact Information Form and Instruction
Informed Consent and Contact Information Att.5d-Consent Form.docx Form and Instruction
Informed Consent and Contact Information Att.5d-Consent Form.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Study Consent and Contact Information	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	n/a	Informed Consent and Contact Information	Att.5d-Consent Form.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title: 09-20-0160, Records of Subjects in Health Promotion and Education Studies	FR Citation: 51 FR 42434

Number of Respondents: 1,570	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	1,570	0	1,570
Annual IC Time Burden (Hours)	131	0	131
Annual IC Cost Burden (Dollars)	0	-3,721	3,721

Documents for IC

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.