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Agenda
Reg Review
ICR
View Information Collection (IC)
View Information Collection (IC)
IC Title:
Developmental Projects and Special Studies
Agency IC Tracking Number:
0920-0950
Is this a Common Form?
No
IC Status:
Modified
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
Instruction
Att_14_Spec_Studies 17-18 101816.docx
Yes
Yes
Printable Only
Form and Instruction
n/a
Forms for the Balance Vestibular Visual Function Pilot Study
Att 1b Balance Forms 081817.docx
No
Paper Only
Other-Protocol for the Infant Blood Draw Pilot Study
Att 2b Blood - Infants Form 083117.docx
No
Paper Only
Other-Link to Protocol for the Words-in-Noise Pilot Study
Att 4b WIN Form 081817.docx
No
Paper Only
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Public Health Monitoring
Privacy Act System of Records
Title:
Health Resources Utilization Statistics
FR Citation:
49 FR 37693
Number of Respondents:
3,500
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
100 %
Approved
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
3,500
0
0
0
0
3,500
Annual IC Time Burden (Hours)
10,500
0
0
0
0
10,500
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
Att Development Project Reports
Att_4_Developmental Project Reports.docx
11/01/2016
Description of the Balance Vestibular Visual Function Study
Att 1a Balance 081817.docx
08/31/2017
Description of the Infant Blood Draw Pilot Study
Att 2a Blood - Infants 083117.docx
08/31/2017
Description of the e-Signature for Consent Pilot Study
Att 3a EConsent Description 083117.docx
08/31/2017
Consent-Assent and Parental Permission Form
Att 3b Adult Consent HC 081817.docx
08/31/2017
Child Assent Form
Att 3c Child Assent HC 081817.docx
08/31/2017
Consent-Assent and Parental Permission Form for Future Research
Att 3d Future Research HC 081817.doc
08/31/2017
Authorization for Transportation Arrangements
Att 3e Transport Auth HC 083117.doc
08/31/2017
Assent Brochure for Children
Att 3f Child_Brochure HC 081817.PDF
08/31/2017
Cover for the Adult Consent Brochure
Att 3g Adult Brochure_Cover HC 081817.pdf
08/31/2017
Contents of the Adult Consent Brochure
Att 3h Adult_Brochure_Inside HC 081817.pdf
08/31/2017
e-Consent (assent) screen for ages 7-11
Att 3i assent 7-11 081817.docx
08/31/2017
e-Consent (assent) screen for ages 12-17
Att 3j assent 12-17 081817.docx
08/31/2017
Description of the Words-in-Noise Pilot Study
Att 4a WIN Description 083117.docx
08/31/2017
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.