Information Collection

Lifestyle and Health History Questionnaire (LHQ)

IC 186342 under ICR 200912-0925-001 · 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⚠️ Notice: This information collection may be referencing outdated material.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 4-3B Lifestyle and Health History Questionnaire (LHQ) Form
Att 4-3A_LHQBurdenPage.pdf aarpwsmsdemo.westat.com/lhqlaunch.asp Instruction
4-3B LHQ instrument Att 4-3B_Instrument LHQ.pdf aarpwsmsdemo.westat.com/lhqlaunch.asp Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Lifestyle and Health History Questionnaire (LHQ)	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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	4-3B	LHQ instrument	Att 4-3B_Instrument LHQ.pdf	http://aarpwsmsdemo.westat.com/lhqlaunch.asp	Yes	Yes	Fillable Fileable
Instruction			Att 4-3A_LHQBurdenPage.pdf	http://aarpwsmsdemo.westat.com/lhqlaunch.asp	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,716	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	Previously Approved
Annual Number of Responses for this IC	3,636	1,920	1,716
Annual IC Time Burden (Hours)	1,212	640	572
Annual IC Cost Burden (Dollars)	0	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.