Information Collection

Phase III Telephone Interview and Buccal Cell Scripts for Agricultural Health Study

IC 185933 under ICR 201005-0925-004 · OMB 0925-0406.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0406 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 2 Phase III Telephone Interview and Buccal Cell Scripts for Agricultural Health Study	Form and Instruction
2 Phase III Interview Script and Consent Attach 3_Phase III Interview Script and Verbal Consent .pdf	Form and Instruction
3 Phase III Buccal Script and Consent Attach 4_Phase III Buccal Script and Verbal Consent .pdf	Form and Instruction
Attach 15_Phase III buccal kit cover letters and instructions.pdf Attach 15A-15G Phase III Buccal Kit Letters, FAQs, etc.	IC Document
Attach 13_Phase III buccal contact scripts and letters.pdf Attach 13A-13D Phase III Buccal Pre-Contact Letters	IC Document

IC Title:

Phase III Telephone Interview and Buccal Cell Scripts for Agricultural Health Study

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 and Instruction	2	Phase III Interview Script and Consent	Attach 3_Phase III Interview Script and Verbal Consent .pdf		Yes	Yes	Fillable Printable
Form and Instruction	3	Phase III Buccal Script and Consent	Attach 4_Phase III Buccal Script and Verbal Consent .pdf		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: SORN #09-25-0200, Clinical, Epidemiologic, and Biometric Studies of the National Institutes of Health (NIH), HHS/NIH/ OD

FR Citation: 67 FR 60776

Number of Respondents: 150

Number of Respondents for Small Entity: 150

Affected Public: Private Sector

Private Sector: Farms

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	150	-181	331
Annual IC Time Burden (Hours)	13	-318	331
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attach 15A-15G Phase III Buccal Kit Letters, FAQs, etc.	Attach 15_Phase III buccal kit cover letters and instructions.pdf	04/29/2010
Attach 13A-13D Phase III Buccal Pre-Contact Letters	Attach 13_Phase III buccal contact scripts and letters.pdf	04/29/2010

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