Information Collection

Study to Improve Thyroid Doses from Fallout Exposure in Kazakhstan

IC 180668 under ICR 200706-0925-001 · OMB 0925-0582.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Study to Improve Thyroid Doses from Fallout Exposure in Kazakhstan	Form
1 Focus Group Guide Appendix A- KAZ Men_FocusGroupGuide-5-14-07[1].pdf	Form
2 Women Appendix B - KAZ Women_FocusGroupGuide_InSession-5-14-07[1].pdf	Form
3 Not in Session Appendix C - KAZ Women_FocusGroupGuide_NOTInSession-5-14-07[1].pdf	Form
4 Evaluation Appendix D - KAZ Post_FocusGroup_Evaluation_Apr2[1].pdf	Form
Appendix E1-IRB Approval-RTI_Apr2[1].pdf Appendix E1-IRB Approval-RTI_Apr2[1]	IC Document
Appendix E2-IRB Approval-SSMA.pdf Appendix E2-IRB Approval-SSMA	IC Document
Appendix F - KAZ Consent Form_Apr2.pdf Appendix F - KAZ Consent Form_Apr2	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	1	Focus Group Guide	Appendix A- KAZ Men_FocusGroupGuide-5-14-07[1].pdf	Yes	Yes	Paper Only
Form	2	Women	Appendix B - KAZ Women_FocusGroupGuide_InSession-5-14-07[1].pdf	Yes	Yes	Paper Only
Form	3	Not in Session	Appendix C - KAZ Women_FocusGroupGuide_NOTInSession-5-14-07[1].pdf	Yes	Yes	Paper Only
Form	4	Evaluation	Appendix D - KAZ Post_FocusGroup_Evaluation_Apr2[1].pdf	Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 128

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	128	128
Annual IC Time Burden (Hours)	256	256
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Appendix E1-IRB Approval-RTI_Apr2[1]	Appendix E1-IRB Approval-RTI_Apr2[1].pdf	05/31/2007
Appendix E2-IRB Approval-SSMA	Appendix E2-IRB Approval-SSMA.pdf	05/31/2007
Appendix F - KAZ Consent Form_Apr2	Appendix F - KAZ Consent Form_Apr2.pdf	05/31/2007

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.