Information Collection

Att 10_Phase 2 Consent

IC 218949 under ICR 202103-0920-007 · OMB 0920-1100.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1100 can be found here:

Documents and Forms

Document Name Document Type
Att 11a_Phase 2 Consent form (English).docx Other-Consent Form (English)
Att 11a_Phase 2 Consent form (English).docx Other-Consent Form (English)
Att 11b_Phase 2 Consent Form (Spanish).docx Other-Consent Form (Spanish)
Att 11b_Phase 2 Consent Form (Spanish).docx Other-Consent Form (Spanish)

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Att 10_Phase 2 Consent	Agency IC Tracking Number:	15AEZ

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
Other-Consent Form (English)			Att 11a_Phase 2 Consent form (English).docx		No		Paper Only
Other-Consent Form (Spanish)			Att 11b_Phase 2 Consent Form (Spanish).docx		No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 50	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	50	50
Annual IC Time Burden (Hours)	13	13
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.