Information Collection

FLUSURV-NET: CONSENT FORM FOR PATIENT/PROXY INTERVIEW (English/Spanish)

IC 207653 under ICR 202505-0920-009 · OMB 0920-0978.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0978 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form FSN.300.2 FLUSURV-NET: CONSENT FORM FOR PATIENT/PROXY INTERVIEW (English/Spanish)	Form and Instruction
Form FSN.300.2 FLUSURV-NET: CONSENT FORM FOR PATIENT/PROXY INTERVIEW FLUSURV-NET: CONSENT FORM FOR PATIENT/PROXY INTERVIEW (English/Spanish)	Form and Instruction
FSN.300.2 FLUSURV-NET: CONSENT FORM FOR PATIENT/PROXY INTERVIEW FSN.300.2 Phone Script and Consent Form.pdf	Form and Instruction
FSN.300.2 FLUSURV-NET: CONSENT FORM FOR PATIENT/PROXY INTERVIEW FSN.300.2 Phone Script and Consent Form.pdf	Form and Instruction

IC Title:

FLUSURV-NET: CONSENT FORM FOR PATIENT/PROXY INTERVIEW (English/Spanish)

Agency IC Tracking Number:

0920-0978

Is this a Common Form? No

IC Status: Unchanged

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 301 Public Health Service Act

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	FSN.300.2			NA	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 13

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	208	208
Annual IC Time Burden (Hours)	34	34
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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