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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
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

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:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.