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Referral/Consent to Contact Form - Patient
Registry of Unexplained Fatiguing Illnesses and Chronic Fatigue Syndrome (CFS): A Pilot Study
OMB: 0920-0788
IC ID: 183859
OMB.report
HHS/CDC
OMB 0920-0788
ICR 200802-0920-009
IC 183859
( )
Documents and Forms
Document Name
Document Type
Form No number
Referral/Consent to Contact Form - Patient
Form
No number Referral/Consent to Contact Form - Patient
Attachment 7 Referral-Consent to Contact Form for Patient.doc
Form
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Referral/Consent to Contact Form - Patient
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
New
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
Form
No number
Referral/Consent to Contact Form - Patient
Attachment 7 Referral-Consent to Contact Form for Patient.doc
Yes
No
Paper Only
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Illness Prevention
Privacy Act System of Records
Title:
Epidemiologic Studies and Surveillance of Disease Problems
FR Citation:
57 FR 62812
Number of Respondents:
507
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
0 %
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
507
0
507
0
0
0
Annual IC Time Burden (Hours)
101
0
101
0
0
0
Annual IC Cost Burden (Dollars)
0
0
0
0
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.
