Information Collection

The Jackson Heart Study: Annual Follow-up with Third Party Respondents

IC 7410 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⚠️ Notice: This information collection may be referencing outdated material.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 The Jackson Heart Study: Annual Follow-up with Third Party Respondents	Form
1 Informant interview Attach 10 -Informant Interview (IFI) Form.doc	Form
2 Confidential Data Attach 13 -Confidential Data (CFD) Form.doc	Form
3 Common Hospital Information Attach 14 - Common Hospital Information (CHI) Form.doc	Form
4 Hospital Abstraction Attach 15-Hospital Abstraction (HRA) Form.doc	Form
5 Cohort Eligibility Attach 16 -Cohort Eligibility (CEL) Form.doc	Form
6 Stroke Abstraction Attach 17 -Stroke Abstraction (STR) Form.doc	Form
7 Heart Failure Survey Attach 18 - Heart Failure Survey (HFS) Form.doc	Form
8 Heart Failure Diagnosis Attach 19-Heart Failure Diagnosis (HDX) Form.doc	Form
9 Hospital Record Abstraction Attach 20 -Hospital Failure Hospital Record Abstraction (HFA) Form.doc	Form
10 Heart Failure Abstraction Attach 21 -Heart Failure Abstraction (HFS-A) Form.doc	Form
Attach #5.doc April 09 OSMB Minutes	IC Document
Attach 9 -Unknown number Letter.doc Attach 9 -Unknown number Letter	IC Document
Attach 8 -Known number_Death certificate contact notification.doc Attach 8 -Known number_Death certificate contact notification	IC Document
JHSFDAP.doc JHSFDAP	IC Document
Attach #4.doc April 08 OSMB Minutes	IC Document
Attach #2.doc OSMB Members 07	IC Document
april 07 OSMB minutes.doc april 07 OSMB minutes	IC Document
Council.doc Council	IC Document

IC Title:

The Jackson Heart Study: Annual Follow-up with Third Party Respondents

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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	1	Informant interview	Attach 10 -Informant Interview (IFI) Form.doc	No	No	Paper Only
Form	2	Confidential Data	Attach 13 -Confidential Data (CFD) Form.doc	Yes	Yes	Paper Only
Form	3	Common Hospital Information	Attach 14 - Common Hospital Information (CHI) Form.doc	Yes	Yes	Paper Only
Form	4	Hospital Abstraction	Attach 15-Hospital Abstraction (HRA) Form.doc	Yes	Yes	Paper Only
Form	5	Cohort Eligibility	Attach 16 -Cohort Eligibility (CEL) Form.doc	Yes	Yes	Paper Only
Form	6	Stroke Abstraction	Attach 17 -Stroke Abstraction (STR) Form.doc	Yes	Yes	Paper Only
Form	7	Heart Failure Survey	Attach 18 - Heart Failure Survey (HFS) Form.doc	Yes	Yes	Paper Only
Form	8	Heart Failure Diagnosis	Attach 19-Heart Failure Diagnosis (HDX) Form.doc	Yes	Yes	Paper Only
Form	9	Hospital Record Abstraction	Attach 20 -Hospital Failure Hospital Record Abstraction (HFA) Form.doc	Yes	Yes	Paper Only
Form	10	Heart Failure Abstraction	Attach 21 -Heart Failure Abstraction (HFS-A) 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: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	200	-400	600
Annual IC Time Burden (Hours)	34	-266	300
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
April 09 OSMB Minutes	Attach #5.doc	03/22/2010
Attach 9 -Unknown number Letter	Attach 9 -Unknown number Letter.doc	03/22/2010
Attach 8 -Known number_Death certificate contact notification	Attach 8 -Known number_Death certificate contact notification.doc	03/22/2010
JHSFDAP	JHSFDAP.doc	05/16/2007
April 08 OSMB Minutes	Attach #4.doc	03/22/2010
OSMB Members 07	Attach #2.doc	03/22/2010
april 07 OSMB minutes	april 07 OSMB minutes.doc	05/16/2007
Council	Council.doc	05/16/2007

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