Information Collection

Diagnostic Safety Supplement

IC 258919 under ICR 202407-0935-001 · OMB 0935-0265.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 5 Diagnostic Safety Supplement	Form and Instruction
5 Attachment E: Diagnostic Safety Supplement Att E_Diagnostic Safety Supplement.docx	Form and Instruction
5 Attachment E: Diagnostic Safety Supplement Att E_Diagnostic Safety Supplement.docx	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Removed

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 and Instruction	5	Attachment E: Diagnostic Safety Supplement	Att E_Diagnostic Safety Supplement.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: 350

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	-700	700
Annual IC Time Burden (Hours)	-140	140
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.