Diet and Health History Questionnaire (DHQ) (Attach 4-4)

The NIH-AARP interactive Comprehensive Lifestyle Interview by Computer Study (iCLIC) (NCI)

Documents and Forms

Document Name Document Type
Form 4 Diet and Health History Questionnaire (DHQ) (Attach 4-4) Form and Instruction
4 DHQ Att 4-4A and 4-4B_Partial DHQ w URL.docx riskfactor.cancer.gov/dhq Form and Instruction

Information Collection (IC) Details

IC Title:	Diet and Health History Questionnaire (DHQ) (Attach 4-4)	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	4	DHQ	Att 4-4A and 4-4B_Partial DHQ w URL.docx	http://riskfactor.cancer.gov/dhq	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

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)	1,458	-789	2,247
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.