Form 12 Generic Data

Attachment_A12_gendata
attach_1gg_8788dtf

OMB#
0925-xxxx
OMB#0925-xxxx
Expiration Date:
Expiration
Date:xx/xx/xxxx
xx/xx/xxxx

Public reporting burden for this collection of information is estimated to average 10 minutes per response, including
reporting
burden
for this collection
information
is estimated
to vary
from
5 to 10 minutes
perneeded,
response,
thePublic
time for
reviewing
instructions,
searchingofexisting
data sources,
gathering
and
maintaining
the data
and
including and
the time
for reviewing
instructions,
searchingAn
existing
gathering
and maintaining
theisdata
completing
reviewing
the collection
of information.
agencydata
maysources,
not conduct
or sponsor,
and a person
not
needed,
completing
and reviewing
the collection
of information.
agency
mayOMB
not control
conductnumber.
or sponsor,
required
toand
respond
to, a collection
of information
unless
it displays a An
currently
valid
Send and
a personregarding
is not required
to respond
collection
of information
unlessofitinformation,
displays a currently
OMB
comments
this burden
estimateto,oraany
other aspect
of this collection
including valid
suggestions
number.
Sendto:
comments
regarding
this burden
or any other
aspect
this collection
information,
forcontrol
reducing
this burden,
NIH, Project
Clearance
Branch,estimate
6705 Rockledge
Drive,
MSCof7974,
Bethesda,ofMD
including suggestions
for reducing this
burden,
to:the
NIH,
Project Clearance
Branch,
6705 Rockledge Drive, MSC 7974,
20892-7974,
ATTN: PRA (0925-xxxx).
Do not
return
completed
form to this
address.
Bethesda, MD 20892-7974, ATTN: PRA (0925-0624).
(0925-xxxx). Do not return the completed form to this address.

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Attachment_A12_gendata
attach_1gg_8788dtf

INSERT STUDY NAME:_______________
INSERT FAX NUMBER: _________________________

Version 3: 07-Oct-2016

OMB#
0925-xxxx
OMB#0925-xxxx
Expiration Date:
xx/xx/xxxx
Expiration
Date:
xx/xx/xxxx