Other Adult Household Member Informed Consent For Study Participation

The Community Choice Demonstration

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2528-0337 can be found here:

Documents and Forms

Document Name Document Type
Revised - Attachment D Other Adult Household Member Informed Consent.docx Other-Revised - Attachment D Other A
Revised - Attachment D Other Adult Household Member Informed Consent.docx Other-Revised - Attachment D Other A

Information Collection (IC) Details

IC Title:	OTHER ADULT HOUSEHOLD MEMBER INFORMED CONSENT FOR STUDY PARTICIPATION	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Removed

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
Other-Revised - Attachment D Other Adult Household Member Informed Consent			Revised - Attachment D Other Adult Household Member Informed Consent.docx		Yes	Yes	Fillable Fileable

Line of Business: Community and Social Services

Subfunction: Community and Regional Development

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 10,100	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	-10,100	10,100
Annual IC Time Burden (Hours)	-2,525	2,525
Annual IC Cost Burden (Dollars)	0	0

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.