Information Collection

CTSU Patient Enrollment Transmittal Form (Attachment A15)

IC 225866 under ICR 202411-0925-001 · OMB 0925-0753.

Documents and Forms

Document Name Document Type
Form 15 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

Information Collection (IC) Details

View Information Collection (IC)

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:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	15	patient Enrollment Transmittal Form	Attachment_A15_ptentf_06152018.pdf		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 %

	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

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.