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⚠️ Notice: This information collection may be referencing outdated material.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

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

Information Collection (IC) Details

View Information Collection (IC)

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:

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 %

	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

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.