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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
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

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:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.