Information Collection

Health Status Questionnaire (HSQ) for PLCO

IC 186212 under ICR 200808-0925-002 · OMB 0925-0407.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0407 can be found here:

Documents and Forms

Document Name Document Type
Form 2 Health Status Questionnaire (HSQ) for PLCO Form
2 Health Status Questionnaire (HSQ) for Males Attachment 4A (HSQ-Male).doc Form
3 Health Status Questionnaire (HSQ) for Females Attachment 4B (HSQ-Female).doc Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Health Status Questionnaire (HSQ) for PLCO	Agency IC Tracking Number:

Is this a Common Form? Yes		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	2	Health Status Questionnaire (HSQ) for Males	Attachment 4A (HSQ-Male).doc		Yes	Yes	Fillable Fileable
Form	3	Health Status Questionnaire (HSQ) for Females	Attachment 4B (HSQ-Female).doc		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,333	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	1,333	1,333
Annual IC Time Burden (Hours)	111	111
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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