Information Collection

Lifestyle and Health History Questionnaire (LHQ) (Attach 4-3)

IC 186342 under ICR 201012-0925-007 · OMB 0925-0594.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 3 Lifestyle and Health History Questionnaire (LHQ) (Attach 4-3)	Form and Instruction
3 LHQ Att 4-3A and 4-3B_Partial LHQ.docx	Form and Instruction
3 LHQ Full Att 4-3B_Full LHQ.pdf	Form and Instruction

IC Title:

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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	3	LHQ	Att 4-3A and 4-3B_Partial LHQ.docx		Yes	Yes	Fillable Fileable
Form and Instruction	3	LHQ Full	Att 4-3B_Full LHQ.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: SORN #09-25-0200, "Clinical, Basic, and Population-based Research Studies of the National Institutes of Health (NIH), HHS/NIH/OD"

FR Citation: 67 FR 60776

Number of Respondents: 1,944

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	1,944	-1,692	3,636
Annual IC Time Burden (Hours)	648	-564	1,212
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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