QUESTIONNAIRE - STOFT TISSUE SARCOMA STUDY

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability

No forms / supporting documents in this ICR. Check IC Document Collections.

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
148198	QUESTIONNAIRE - STOFT TISSUE SARCOMA STUDY	Form	Migrated

ICR Details

OMB Control No:	ICR Reference No: 198404-2900-006
Status: Historical Inactive	Previous ICR Reference No:
Agency/Subagency: VA	Agency Tracking No:
Title: QUESTIONNAIRE - STOFT TISSUE SARCOMA STUDY
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Disapproved	Conclusion Date: 07/20/1984
	Date Received in OIRA: 04/25/1984
Terms of Clearance: NOT APPROVED. AS DISCUSSED BETWEEN OMB AND VA OFFICIALS, THE FOLLOWING STEPS MUST BE TAKEN IN ORDER TO OBTAIN APPROVAL: 1) VA MUST RECEIVE FORMAL APPROVAL FROM THE AGENT ORANGE CABINET COUNCIL WORKING GROUP, 2) QUESTIONS B6, B7, B 12 AND B13 MUST BE DELETED, 3) THE NUMBER OF CONTROLS PER CASE SHOULD BE INCREASED IF FEASIBLE, 4) VA SHOULD RE-FORMULATE THE MEDICAL HISTORY SECTION TO MAKE IT AS COMPARABLE AS POSSIBLE TO CDC'S FORMAT. RE-SUBMISSION SHOULD BE MADE AS SOON AS THESE CONDITIONS HAVE BEEN MET.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date
Responses	0	0	0
Time Burden (Hours)	0	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: VA AGENT ORANGE STUDY TO DETERMINE WHETHER VETERANS WHO SERVED IN VIETNAM MIGHT BE AT INCREASED RISK OF DEVELOPING SOFT TISSUE SARCOMA DUE TO EXPOSURE TO PHENOXY HERBICIDES INCLUDING AGENT ORANGE. INVOLVES UP TO 1,320 INTERVIEWS.

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Authorizing Statute(s): None

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:

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Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
QUESTIONNAIRE - STOFT TISSUE SARCOMA STUDY	10-20763, (NR)

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Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $0

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 04/25/1984

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