Information Collection

Individuals

IC 7259 under ICR 200801-0925-004 · OMB 0925-0216.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0216 can be found here:

Documents and Forms

Document Name Document Type
Form 1 Individuals Form and Instruction
1 Form OriginalCohortExamSchedulingForm.doc Form and Instruction
2 Form OriginalCohortappointmentconfirmation.doc Form and Instruction
3 Form OriginalCohortExaminationForms.doc Form and Instruction
4 Form Gen3Exam2 ExamSchedulingForm.doc Form and Instruction
5 Form Gen3Exam2AppointmentConfirmation.doc Form and Instruction
6 Form Gen3Exam2ExamForms.doc Form
7 Form OriginalandGen3CellLine.doc Form and Instruction
8 Form PreCTscan.doc Form and Instruction
9 Form PostCTscan.doc Form and Instruction
10 Form Food Frequency.doc Form and Instruction
11 Form RecordsRequestFormsandCoverletters.doc Form and Instruction
LettertoParticipantsnottakingExam.doc LettertoParticipantsnottakingExam IC Document
CTConsentForm.doc CTConsentForm IC Document
OriginalandGen3ConsentForms.doc OriginalandGen3ConsentForms IC Document
CTIncidentalFindingReport.doc CTIncidentalFindingReport IC Document
ParticipantResultsLetters.doc ParticipantResultsLetters IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Individuals	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	1	Form	OriginalCohortExamSchedulingForm.doc	Yes	Yes	Paper Only
Form and Instruction	2	Form	OriginalCohortappointmentconfirmation.doc	Yes	Yes	Paper Only
Form and Instruction	3	Form	OriginalCohortExaminationForms.doc	Yes	Yes	Paper Only
Form and Instruction	4	Form	Gen3Exam2 ExamSchedulingForm.doc	Yes	Yes	Paper Only
Form and Instruction	5	Form	Gen3Exam2AppointmentConfirmation.doc	Yes	Yes	Paper Only
Form	6	Form	Gen3Exam2ExamForms.doc	Yes	Yes	Paper Only
Form and Instruction	7	Form	OriginalandGen3CellLine.doc	Yes	Yes	Paper Only
Form and Instruction	8	Form	PreCTscan.doc	Yes	Yes	Paper Only
Form and Instruction	9	Form	PostCTscan.doc	Yes	Yes	Paper Only
Form and Instruction	10	Form	Food Frequency.doc	Yes	Yes	Paper Only
Form and Instruction	11	Form	RecordsRequestFormsandCoverletters.doc	Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 4,719	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	5,224	5,224
Annual IC Time Burden (Hours)	5,224	5,224
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
LettertoParticipantsnottakingExam	LettertoParticipantsnottakingExam.doc	01/24/2008
CTConsentForm	CTConsentForm.doc	01/24/2008
OriginalandGen3ConsentForms	OriginalandGen3ConsentForms.doc	01/24/2008
CTIncidentalFindingReport	CTIncidentalFindingReport.doc	01/24/2008
ParticipantResultsLetters	ParticipantResultsLetters.doc	01/24/2008

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