Information Collection

Diet and Health History Questionnaire (DHQ)

IC 186343 under ICR 200808-0925-004 · OMB 0925-0594.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0594 can be found here:

Documents and Forms

Document Name Document Type
Form 4-4B Diet and Health History Questionnaire (DHQ) Form
Att 4-4A_DHQBurdenPage.pdf riskfactor.cancer.gov/DHQ/ Instruction
4-4B DHQ instrument Att 4-4B_Instrument DHQ Paper Version.pdf riskfactor.cancer.gov/DHQ/ Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Diet and Health History Questionnaire (DHQ)	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	4-4B	DHQ instrument	Att 4-4B_Instrument DHQ Paper Version.pdf	http://riskfactor.cancer.gov/DHQ/	Yes	Yes	Fillable Fileable
Instruction			Att 4-4A_DHQBurdenPage.pdf	http://riskfactor.cancer.gov/DHQ/	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,036	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,036	1,036
Annual IC Time Burden (Hours)	777	777
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.