Sub-Study memo

Date:

To: Office of Management and Budget (OMB)

Through: DHHS Report Clearance Officer

Seleda Perryman, NIH Project Clearance Officer, OPERA

Sarah Glavin, NICHD Project Clearance Liaison

From:

Subject: Generic Sub-Study, Title of Sub-study

(OMB No. 0925-XXXX)

Abstract and/or background information on the study/project.

Circumstances Making the Collection of Information Necessary

Describe what make the information collection necessary

Purpose and Use of the Information Collection

Describe the purpose of the information collection, including information on the respondent group; use of an incentive; whether the collection is voluntary, mandatory, or required for benefits; if personally identifiable information (PII) will be collected; and how the information will be securely stored.

Estimate of Burden Hours and Costs

Provide the category of respondent (e.g., Individual-Household, Private Sector, or State/Local/Tribal/Federal governments); number of respondents for this collection, time (e.g., x/60), and response burden.

Category of Respondent	No. of Respondents	Participation Time	Response Burden
Totals

1