Information Collection

Parent or Caregiver Consent

IC 264291 under ICR 202501-0925-002 · OMB 0925-0781.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Parent or Caregiver Consent	Form
Form 1 Consent Parent or Caregiver Consent	Form
1 Consent Att B - Parent Caregiver Consent dated 03-20-24 Stamped.pdf	Form
1 Consent Att B - Parent Caregiver Consent dated 03-20-24 Stamped.pdf	Form
Att B - Parent Caregiver Consent SPANISH dated 03-20-24 Stamped.pdf Consent Spanish	IC Document
Att B - Parent Caregiver Consent SPANISH dated 03-20-24 Stamped.pdf Consent Spanish	IC Document

IC Title:

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	1				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 15

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Previously Approved
Annual Number of Responses for this IC	15	15
Annual IC Time Burden (Hours)	1	1
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Consent Spanish		09/30/2024

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

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