Information Collection

Biospecimen Request

IC 233987 under ICR 202412-0925-001 · OMB 0925-0744.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Biospecimen Request	Form
Form 1 Biospecimen Request Biospecimen Request	Form
1 Biospecimen Request Attachment A.2-5_Biospecimen Request_OMB 0925-0744_2024 0215.docx	Form
1 Biospecimen Request Attachment A.2-5_Biospecimen Request_OMB 0925-0744_2024 0215.docx	Form
Manual Biospecimen Request Submission Form - UAT.pdf Manual Biospecimen Request Submission Form	IC Document
Manual Biospecimen Request Submission Form - UAT.pdf Manual Biospecimen Request Submission Form	IC Document

IC Title:

Biospecimen Request

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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	1				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: Clinical, Basic and Population-based Research Studies of the National Institutes of Health (NIH), HHS/NIH/OD

FR Citation: 67 FR 60742

Number of Respondents: 4

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	4	4
Annual IC Time Burden (Hours)	4	4
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Manual Biospecimen Request Submission Form		12/10/2024

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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