Information Collection

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

IC 7410 under ICR 201005-0925-006 · OMB 0925-0491.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0491 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 The Jackson Heart Study: Annual Follow-up with Third Party Respondents	Form and Instruction
1 survey Attach 10 -Informant Interview (IFI) Form.doc	Form and Instruction
2 survey Attach 13 -Confidential Data (CFD) Form.doc	Form and Instruction
3 survey Attach 14 - Common Hospital Information (CHI) Form.doc	Form and Instruction
4 survey Attach 15-Hospital Abstraction (HRA) Form.doc	Form and Instruction
5 survey Attach 16 -Cohort Eligibility (CEL) Form.doc	Form and Instruction
6 survey Attach 17 -Stroke Abstraction (STR) Form.doc	Form and Instruction
7 survey Attach 18 - Heart Failure Survey (HFS) Form.doc	Form and Instruction
9 survey Attach 20 -Hospital Failure Hospital Record Abstraction (HFA) Form.doc	Form and Instruction
10 survey Attach 21 -Heart Failure Abstraction (HFS-A) Form.doc	Form and Instruction
8 survey Attach 19-Heart Failure Diagnosis (HDX) Form.doc	Form and Instruction
Attach #6.doc JHSDAP	IC Document
Attach 8 -Known number_Death certificate contact notification.doc Attach 8 -Known number_Death certificate contact notification	IC Document
Attach 9 -Unknown number Letter.doc Attach 9 -Unknown number Letter	IC Document
Attach #4.doc April 08 OSMB	IC Document
Attach #3.doc April 2007 OSMB	IC Document
Attach #5.doc April 2009 OSMB	IC Document
Attach #2.doc OSMB Members	IC Document
Attach #1.doc Council	IC Document
Privacy Act- Attachment #7.doc Privacy Act Memo	IC Document

IC Title:

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

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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	1	survey	Attach 10 -Informant Interview (IFI) Form.doc	Yes	Yes	Paper Only
Form and Instruction	2	survey	Attach 13 -Confidential Data (CFD) Form.doc	Yes	Yes	Paper Only
Form and Instruction	3	survey	Attach 14 - Common Hospital Information (CHI) Form.doc	Yes	Yes	Paper Only
Form and Instruction	4	survey	Attach 15-Hospital Abstraction (HRA) Form.doc	Yes	Yes	Paper Only
Form and Instruction	5	survey	Attach 16 -Cohort Eligibility (CEL) Form.doc	Yes	Yes	Paper Only
Form and Instruction	6	survey	Attach 17 -Stroke Abstraction (STR) Form.doc	Yes	Yes	Paper Only
Form and Instruction	7	survey	Attach 18 - Heart Failure Survey (HFS) Form.doc	Yes	Yes	Paper Only
Form and Instruction	9	survey	Attach 20 -Hospital Failure Hospital Record Abstraction (HFA) Form.doc	Yes	Yes	Paper Only
Form and Instruction	10	survey	Attach 21 -Heart Failure Abstraction (HFS-A) Form.doc	Yes	Yes	Paper Only
Form and Instruction	8	survey	Attach 19-Heart Failure Diagnosis (HDX) Form.doc	Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 200

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	200	-400	600
Annual IC Time Burden (Hours)	34	-266	300
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
JHSDAP	Attach #6.doc	05/13/2010
Attach 8 -Known number_Death certificate contact notification	Attach 8 -Known number_Death certificate contact notification.doc	05/13/2010
Attach 9 -Unknown number Letter	Attach 9 -Unknown number Letter.doc	05/13/2010
April 08 OSMB	Attach #4.doc	05/13/2010
April 2007 OSMB	Attach #3.doc	05/13/2010
April 2009 OSMB	Attach #5.doc	05/13/2010
OSMB Members	Attach #2.doc	05/13/2010
Council	Attach #1.doc	05/13/2010
Privacy Act Memo	Privacy Act- Attachment #7.doc	05/13/2010

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