Information Collection

Health Status Questionnaire (HSQ) for PLCO

IC 186212 under ICR 201107-0925-004 · OMB 0925-0407.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0407 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 2a Health Status Questionnaire (HSQ) for PLCO	Form
2a Health Status Questionnaire (HSQ) for Males Attach_04A_HSQ-Male.doc	Form
2b Health Status Questionnaire (HSQ) for Females Attach_04B_HSQ-Female.doc	Form

IC Title:

Health Status Questionnaire (HSQ) for PLCO

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	2a	Health Status Questionnaire (HSQ) for Males	Attach_04A_HSQ-Male.doc		Yes	No	Fillable Fileable
Form	2b	Health Status Questionnaire (HSQ) for Females	Attach_04B_HSQ-Female.doc		Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title: 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: 2,000

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	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	2,000	667	1,333
Annual IC Time Burden (Hours)	167	56	111
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.