Short Follow-Up Questionnaire For The National Institutes of Health (NIH)-AARP Diet and Health Study (NCI)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 1 NIH Diet and Health Study Questionnaire	Form and Instruction	Modified	Available
SSB_03-31-2011.docx	Supporting Statement B	Uploaded 2011-04-06	Available
Att11_NIH Certificate of confidentiality Diet and Health Study.pdf	Supplementary Document	Uploaded 2011-04-06	Available
Att10_Waves 1-4 Follow-up_letters.pdf	Supplementary Document	Uploaded 2011-04-06	Available
Att9_IRB Approval_ 2010 Diet and Health Study.pdf	Supplementary Document	Uploaded 2011-04-06	Available
Att8_IRB Approval_Short Qx.pdf	Supplementary Document	Uploaded 2011-04-06	Available
Att7_Confidentiality Procedures Westat.pdf	Supplementary Document	Uploaded 2011-04-06	Available
Att6_Privacy Act Memo.pdf	Supplementary Document	Uploaded 2011-04-06	Available
Att5_ External Working Group.pdf	Supplementary Document	Uploaded 2011-04-06	Available
Att4_ Steering Commiittee Members.pdf	Supplementary Document	Uploaded 2011-04-06	Available
Att3_Bibliography Nov 2010.pdf	Supplementary Document	Uploaded 2011-04-06	Available
Att1_Original Study Protocol Summary.pdf	Supplementary Document	Uploaded 2011-04-06	Available
Cover Memo _NIH-AARP_02-2011.doc	Supplementary Document	Uploaded 2011-04-06	Available
SSA_NIH-AARP_03-31-2011.docx	Supporting Statement A	Uploaded 2011-04-06	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
183704	NIH Diet and Health Study Questionnaire	Form and Instruction	Modified

ICR Details

OMB Control No: 0925-0587	ICR Reference No: 201104-0925-001
Status: Historical Active	Previous ICR Reference No: 200802-0925-002
Agency/Subagency: HHS/NIH	Agency Tracking No:
Title: Short Follow-Up Questionnaire For The National Institutes of Health (NIH)-AARP Diet and Health Study (NCI)
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 05/06/2011
	Date Received in OIRA: 04/08/2011
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	05/31/2014	36 Months From Approved	05/31/2011
Responses	485,909	0	513,225
Time Burden (Hours)	32,394	0	34,215
Cost Burden (Dollars)	0	0	0

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Abstract: The Short Follow-Up Questionnaire is needed in order to obtain information on selected medical conditions, medical procedures, and physical and lifestyle status from 485,909 participants in the NIH-AARP Diet and Health Study cohort. The information will be used for the ongoing examination between health and lifestyle behaviors and cancer. A pilot study conducted in 2010 demonstrated using the US Postal Service to distribute and collect completed Short Follow-Up Questionnaires as a feasible approach. Among a sample of 1,600 randomly selected individuals from the original NIH-AARP cohort, a response rate of 63.0% was obtained among participants known to be alive and who received the questionnaire. This is a request for an extension to collect information from additional respondents who were not sampled during the last request period due to a delay in funding.

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Authorizing Statute(s): US Code: 42 USC 412 (285a-1) Name of Law: Public Health Service Act
   US Code: 42 USC 413 (285a-2) Name of Law: Public Health Service Act
  

Citations for New Statutory Requirements: None

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

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 6485	02/04/2011
30-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 19102	04/06/2011
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
NIH Diet and Health Study Questionnaire	1	NIH Diet and Health Study Questionnaire

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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	485,909	513,225	0	0	-27,316	0
Annual Time Burden (Hours)	32,394	34,215	0	0	-1,821	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:

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Annual Cost to Federal Government: $96,228

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

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]? No

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

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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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: 04/08/2011

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