The Jackson Heart Study: Annual Follow-up with Third Party Respondents (NHLBI)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 8 survey	Form and Instruction	Modified	Available
Form 10 survey	Form and Instruction	Modified	Available
Form 9 survey	Form and Instruction	Modified	Available
Form 7 survey	Form and Instruction	Modified	Available
Form 6 survey	Form and Instruction	Modified	Available
Form 5 survey	Form and Instruction	Modified	Available
Form 4 survey	Form and Instruction	Modified	Available
Form 3 survey	Form and Instruction	Modified	Available
Form 2 survey	Form and Instruction	Modified	Available
Form 1 survey	Form and Instruction	Modified	Available
Form 2 survey	Form and Instruction	New	Available
Form 1 survey	Form and Instruction	New	Available
JHS Publications 2007 -2009.pdf	Supplementary Document	Uploaded 2010-05-13	Available
Privacy Act- Attachment #7.doc	Supplementary Document	Uploaded 2010-05-13	Available
Attach #1.doc	Supplementary Document	Uploaded 2010-05-13	Available
Attach #2.doc	Supplementary Document	Uploaded 2010-05-13	Repair queued
Attach #5.doc	Supplementary Document	Uploaded 2010-05-13	Available
Attach #3.doc	Supplementary Document	Uploaded 2010-05-13	Available
Attach #4.doc	Supplementary Document	Uploaded 2010-05-13	Available
Attach 9 -Unknown number Letter.doc	Supplementary Document	Uploaded 2010-05-13	Available
Attach 8 -Known number_Death certificate contact notification.doc	Supplementary Document	Uploaded 2010-05-13	Repair queued
Attach #6.doc	Supplementary Document	Uploaded 2010-05-13	Available
FINAL SUPPORTING STATEMENT PART A revised 03.15.10.doc	Supporting Statement A	Uploaded 2010-05-13	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
7410	The Jackson Heart Study: Annual Follow-up with Third Party Respondents	Form and Instruction	Modified	survey
7410	The Jackson Heart Study: Annual Follow-up with Third Party Respondents	Form and Instruction	Modified	survey
7410	The Jackson Heart Study: Annual Follow-up with Third Party Respondents	Form and Instruction	Modified	survey
7410	The Jackson Heart Study: Annual Follow-up with Third Party Respondents	Form and Instruction	Modified	survey
7410	The Jackson Heart Study: Annual Follow-up with Third Party Respondents	Form and Instruction	Modified	survey
7410	The Jackson Heart Study: Annual Follow-up with Third Party Respondents	Form and Instruction	Modified	survey
7410	The Jackson Heart Study: Annual Follow-up with Third Party Respondents	Form and Instruction	Modified	survey
7410	The Jackson Heart Study: Annual Follow-up with Third Party Respondents	Form and Instruction	Modified	survey
7410	The Jackson Heart Study: Annual Follow-up with Third Party Respondents	Form and Instruction	Modified	survey
7410	The Jackson Heart Study: Annual Follow-up with Third Party Respondents	Form and Instruction	Modified	survey
192889	Jackson Heart Study Annual Follow-up with Third Party Respondents- Physicians	Form and Instruction	New	survey
192889	Jackson Heart Study Annual Follow-up with Third Party Respondents- Physicians	Form and Instruction	New	survey

ICR Details

OMB Control No: 0925-0491	ICR Reference No: 201005-0925-006
Status: Historical Active	Previous ICR Reference No: 200705-0925-006
Agency/Subagency: HHS/NIH	Agency Tracking No:
Title: The Jackson Heart Study: Annual Follow-up with Third Party Respondents (NHLBI)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 06/15/2010
Retrieve Notice of Action (NOA)	Date Received in OIRA: 05/14/2010
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2013	36 Months From Approved	08/31/2010
Responses	400	0	600
Time Burden (Hours)	84	0	300
Cost Burden (Dollars)	0	0	0

---

Abstract: This is a request for collection of follow-up information from third party individuals (next-of-kin descendants and physicians) for the participants in the Jackson Heart Study (JHS) Follow-up. The information is necessary to complete the determination of causes of morbidity and mortality in the JHS Cohort and will be used by the public and private sector for public health planning, medical education, other epidemiologic studies, and biomedical research.

---

Authorizing Statute(s): US Code: 42 USC 285b-3 Name of Law: Publics Health Service Act
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	75 FR 1789	01/13/2010
30-day Notice:	Federal Register Citation:	Citation Date:
	75 FR 17744	04/07/2010
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 2

table that charts list of burden

IC Title	Form No.	Form Name
Jackson Heart Study Annual Follow-up with Third Party Respondents- Physicians	1, 2	survey ,   survey
The Jackson Heart Study: Annual Follow-up with Third Party Respondents	1, 2, 3, 4, 5, 6, 7, 9, 10, 8	survey ,   survey ,   survey ,   survey ,   survey ,   survey ,   survey ,   survey ,   survey ,   survey

---

ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	400	600	0	0	-200	0
Annual Time Burden (Hours)	84	300	0	0	-216	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

---

Annual Cost to Federal Government: $6,459,000

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

---

Common Form ICR:  No

---

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 05/14/2010

---