Information Collection

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

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

Documents and Forms

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

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Lifestyle and Health History Questionnaire (LHQ) (Attach 4-3)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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	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 %

	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

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.