Information Collection

Jackson Heart Study Physicians

IC 192849 under ICR 201005-0925-002 · OMB 0925-0491.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0491 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Jackson Heart Study Physicians	Form
1 Physician Questionnniare Attach 11-Physician Questionnaire (PHQ) Form.doc	Form
2 Coroner-Medical Examiner Attach 12 -Coroner-Medical Examiner (COR) Form.doc	Form

IC Title:

Jackson Heart Study Physicians

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

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	1	Physician Questionnniare	Attach 11-Physician Questionnaire (PHQ) Form.doc		Yes	Yes	Paper Only
Form	2	Coroner-Medical Examiner	Attach 12 -Coroner-Medical Examiner (COR) Form.doc		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 200

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	200	200
Annual IC Time Burden (Hours)	50	50
Annual IC Cost Burden (Dollars)	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.