Information Collection

BEEA Home Visit CAPI for Agricultural Health Study

IC 192872 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⚠️ Notice: This information collection may be referencing outdated material.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 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

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:

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	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 %

table that charts list of burden
	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

table that charts IC Documents
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.