Information Collection

Phase III Buccal Cell Reminder, Missing or Damaged Scripts for Agricultural Health Study

IC 192868 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⚠️ Notice: This information collection may be referencing outdated material.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 5 Phase III Buccal Cell Reminder, Missing or Damaged Scripts for Agricultural Health Study	Form and Instruction
5 Attach 17A Buccal Missing Script Attach 17A_Buccal Cell Missing Consent Form Script Iowa.doc	Form and Instruction
6 Attach 18A Buccal Script for Missing or Damaged Samples Attach 18A_Buccal Recontact Script for Damaged or Missing Buccal Sample Iowa.doc	Form and Instruction
4 Attach 16 Buccal Reminder Script Attach 16_Phase III Buccal Reminder Script.pdf	Form and Instruction
Attach 18B_Buccal Remail Kit Cover Letter Iowa.doc Attach 18B_Buccal Remail Kit Cover Letter Iowa	IC Document
Attach 17B_Buccal Remail Consent Form Cover Letter Iowa.rtf Attach 17B_Buccal Remail Consent Form Cover Letter Iowa	IC Document

IC Title:

Phase III Buccal Cell Reminder, Missing or Damaged Scripts for Agricultural Health Study

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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	5	Attach 17A Buccal Missing Script	Attach 17A_Buccal Cell Missing Consent Form Script Iowa.doc	Yes	Yes	Fillable Printable
Form and Instruction	6	Attach 18A Buccal Script for Missing or Damaged Samples	Attach 18A_Buccal Recontact Script for Damaged or Missing Buccal Sample Iowa.doc	No	No	Fillable Printable
Form and Instruction	4	Attach 16 Buccal Reminder Script	Attach 16_Phase III Buccal Reminder Script.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
Annual Number of Responses for this IC	150	150
Annual IC Time Burden (Hours)	13	13
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attach 18B_Buccal Remail Kit Cover Letter Iowa	Attach 18B_Buccal Remail Kit Cover Letter Iowa.doc	04/29/2010
Attach 17B_Buccal Remail Consent Form Cover Letter Iowa	Attach 17B_Buccal Remail Consent Form Cover Letter Iowa.rtf	04/29/2010

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