BEEA Home Visit CAPI for Agricultural Health Study

Agricultural Health Study: A Prospective Cohort Study of Cancer and Other Diseases Among Men and Women in Agriculture (NCI)

⚠️ Notice: This information collection may be referencing outdated material.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 12 BEEA Home Visit CAPI for Agricultural Health Study Form and Instruction
12 Attach 19 BEEA CAPI Attach 19_CAPI Questionnaire_Both Groups - 03-22-10 rev.doc Form and Instruction
Attach 25A&B_BEEA Advance Letters for First Post-Diazinon Application Visit.pdf Attach 25A-25B BEEA Advance Letters for First Post-Application Visit IC Document
Attach 27_Letter for CBC lymphocyte assay results_NCI_generic.doc Attach 27_Letter for CBC lymphocyte assay results_NCI_generic IC Document

Information Collection (IC) Details

IC Title:	BEEA Home Visit CAPI 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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	12	Attach 19 BEEA CAPI	Attach 19_CAPI Questionnaire_Both Groups - 03-22-10 rev.doc		Yes	Yes	Fillable Fileable

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: 10	Number of Respondents for Small Entity: 10

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	30	30
Annual IC Time Burden (Hours)	10	10
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Attach 25A-25B BEEA Advance Letters for First Post-Application Visit	Attach 25A&B_BEEA Advance Letters for First Post-Diazinon Application Visit.pdf	04/29/2010
Attach 27_Letter for CBC lymphocyte assay results_NCI_generic	Attach 27_Letter for CBC lymphocyte assay results_NCI_generic.doc	04/29/2010

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