Information Collection

Completes, Pilot

IC 232118 under ICR 201907-0910-021 · OMB 0910-0861.

Documents and Forms

Document Name Document Type
Appendix B Questionnaires.docx Other-Survey
Appendix C Consent Form.docx Other-Consent Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Completes, Pilot	Agency IC Tracking Number:	CDER

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-Survey			Appendix B Questionnaires.docx		Yes	Yes	Fillable Fileable
Other-Consent Form			Appendix C Consent Form.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 40	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	40	40
Annual IC Time Burden (Hours)	40	40
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.