Information Collection

CTSU Patient Enrollment Transmittal Form (Attachment A15)

IC 225866 under ICR 202408-0925-004 · OMB 0925-0753.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0753 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 15 CTSU Patient Enrollment Transmittal Form (Attachment A15)	Form and Instruction
Form 15 patient Enrollment Transmittal Form CTSU Patient Enrollment Transmittal Form (Attachment A15)	Form and Instruction
15 patient Enrollment Transmittal Form Attachment_A15_ptentf_06152018.pdf	Form and Instruction
15 patient Enrollment Transmittal Form Attachment_A15_ptentf_06152018.pdf	Form and Instruction

IC Title:

CTSU Patient Enrollment Transmittal Form (Attachment A15)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

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	15				No		Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: Clinical Basic and Population-based Research Studies of the National Institutes of Health

FR Citation: 67 FR 60742

Number of Respondents: 12

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: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	144	144
Annual IC Time Burden (Hours)	24	24
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.

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