The Hispanic Community Health Study/ Study of Latinos (HCHS/SOL)(NHLBI)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 6 Interview	Form and Instruction	New	Available
Form 5 Interview	Form and Instruction	New	Available
Form 4 Interview	Form and Instruction	New	Available
Form 3 Interview	Form and Instruction	New	Available
Form 1 survey	Form and Instruction	Removed	Available
Form 21 Well Being	Form and Instruction	Removed	Repair queued
Form 20 Weight History	Form and Instruction	Removed	Available
Form 19 Tobacco Use	Form and Instruction	Removed	Available
Form 18 Social Cultural	Form and Instruction	Removed	Available
Form 17 Sleep	Form and Instruction	Removed	Available
Form 16 SF12	Form and Instruction	Removed	Available
Form 15 Respiratory	Form and Instruction	Removed	Available
Form 14 Physical Activity	Form and Instruction	Removed	Available
Form 13 Personal Information	Form and Instruction	Removed	Available
Form 12 Oral Health	Form and Instruction	Removed	Available
Form 11 Occupation	Form and Instruction	Removed	Available
Form 2 Informant Interview	Form and Instruction	Modified	Available
Form 1 Questionaire	Form and Instruction	Modified	Available
Form 7 survey	Form and Instruction	Removed	Available
Form 4 survey	Form and Instruction	Removed	Available
Form 6 survey	Form and Instruction	Removed	Available
Form 5 survey	Form and Instruction	Removed	Available
Form 2 survey	Form and Instruction	Removed	Available
Form 3 Informant	Form and Instruction	Removed	Available
Form 1 Recall	Form and Instruction	Removed	Available
Form 23 survey	Form and Instruction	Removed	Available
Form 22 survey	Form and Instruction	Removed	Available
Form 21 Well Being	Form and Instruction	Removed	Available
Form 20 Weight History	Form and Instruction	Removed	Available
Form 19 Tobacco Use	Form and Instruction	Removed	Available
Form 18 Social Cultural	Form and Instruction	Removed	Available
Form 17 Sleep	Form and Instruction	Removed	Repair queued
Form 16 SF 12	Form and Instruction	Removed	Available
Form 15 Respiratory	Form and Instruction	Removed	Available
Form 14 Physical Activity	Form and Instruction	Removed	Available
Form 12 Oral Health	Form and Instruction	Removed	Available
Form 11 Occupation	Form and Instruction	Removed	Available
Form 10 Neuro	Form and Instruction	Removed	Available
Form 9 Medication Use	Form and Instruction	Removed	Available
Form 8 Medical History	Form and Instruction	Removed	Available
Form 7 Informed Consent	Form and Instruction	Removed	Available
Form 6 Hearing Exam	Form and Instruction	Removed	Available
Form 5 Health Care Use	Form and Instruction	Removed	Available
Form 4 Economic	Form and Instruction	Removed	Available
Form 3 Dietary Behavior	Form and Instruction	Removed	Available
Form 2 Dietary Recall and Supplement Use	Form and Instruction	Removed	Available
Form 1 Alcohol Use	Form and Instruction	Removed	Available
Form 21 Well Being	Form and Instruction	Removed	Available
Form 20 Weight History	Form and Instruction	Removed	Available
Form 19 Tobacco Use	Form and Instruction	Removed	Available
Form 18 Social Cultural	Form and Instruction	Removed	Available
Form 17 Sleep	Form and Instruction	Removed	Available
Form 16 SF 12	Form and Instruction	Removed	Available
Form 15 Respiratory	Form and Instruction	Removed	Available
Form 14 Physical Activity	Form and Instruction	Removed	Available
Form 13 Personal Information	Form and Instruction	Removed	Available
Form 12 Oral Health	Form and Instruction	Removed	Available
Form 10 Neuro	Form and Instruction	Removed	Available
Form 9 Medication Use	Form and Instruction	Removed	Available
Form 8 Medical History	Form and Instruction	Removed	Available
Form 7 Informed Consent	Form and Instruction	Removed	Available
Form 6 Hearing Exam	Form and Instruction	Removed	Available
Form 5 Health Care Use	Form and Instruction	Removed	Available
Form 4 Economic	Form and Instruction	Removed	Available
Form 3 Dietary Behavior	Form and Instruction	Removed	Available
Form 2 Dietary Recall and Supplement Use	Form and Instruction	Removed	Available
Form 1 Alcohol Use	Form and Instruction	Removed	Repair queued
Form 11 Occupation	Form and Instruction	Removed	Available
Form 1 Food Propensity	Form	Modified	Available
Form 2 Interview	Form and Instruction	Modified	Available
Form 1 Interview	Form and Instruction	Modified	Available
Final HCHS. B. Supporting Statement.11.23.11.docx	Supporting Statement B	Uploaded 2011-11-30	Available
UNC_Approval_03-2011.pdf	Supplementary Document	Uploaded 2011-10-07	Available
San Diego_Talavera_ HIPPA_English.pdf	Supplementary Document	Uploaded 2011-10-07	Available
San Diego_Talavera_3677_SOL_IRB Renewal .pdf	Supplementary Document	Uploaded 2011-10-07	Available
Miami_HIPAA_Form_English.pdf	Supplementary Document	Uploaded 2011-10-07	Available
Miami_HCHS IRB Continuing Approval letter 041511 (2).pdf	Supplementary Document	Uploaded 2011-10-07	Available
Albert Einstein HIPPA_Updated English HIPAA .pdf	Supplementary Document	Uploaded 2011-10-07	Available
Albert Einstein COM HCHS IRB approval_012011.pdf	Supplementary Document	Uploaded 2011-10-07	Available
Northwestern Univ_Approval HCHS 2010-2011.pdf	Supplementary Document	Uploaded 2011-10-07	Available
8. HCHS budget.xlsm	Supplementary Document	Uploaded 2011-10-07	Available
7. HCHS Privacy Policy.docm	Supplementary Document	Uploaded 2011-10-07	Available
6. OSMB Minutes.2010.pdf	Supplementary Document	Uploaded 2011-10-07	Available
5. NHLBI Council Minutes.2004.docm	Supplementary Document	Uploaded 2011-10-07	Available
4.Working Group Report Aug 11 2010.doc	Supplementary Document	Uploaded 2011-10-07	Available
3. Epidemiologic Research in Hispanic Populations2003.docm	Supplementary Document	Uploaded 2011-10-07	Available
2. Timeline for Annual Follow.ps.doc	Supplementary Document	Uploaded 2011-10-07	Available
1. Privacy Act Memo.pdf	Supplementary Document	Uploaded 2011-10-07	Available
Final.HCHS.A. Supporting Statement.11.23.11.docx	Supporting Statement A	Uploaded 2011-11-30	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
199868	Participants Follow-up Year 3 to 6	Form and Instruction	New	Interview
199868	Participants Follow-up Year 3 to 6	Form and Instruction	New	Interview
199868	Participants Follow-up Year 3 to 6	Form and Instruction	New	Interview
199868	Participants Follow-up Year 3 to 6	Form and Instruction	New	Interview
187780	Food Propensity	Form and Instruction	Removed	survey
183722	Focus Groups	Form and Instruction	Removed	Well Being
183722	Focus Groups	Form and Instruction	Removed	Weight History
183722	Focus Groups	Form and Instruction	Removed	Tobacco Use
183722	Focus Groups	Form and Instruction	Removed	Social Cultural
183722	Focus Groups	Form and Instruction	Removed	Sleep
183722	Focus Groups	Form and Instruction	Removed	SF12
183722	Focus Groups	Form and Instruction	Removed	Respiratory
183722	Focus Groups	Form and Instruction	Removed	Physical Activity
183722	Focus Groups	Form and Instruction	Removed	Personal Information
183722	Focus Groups	Form and Instruction	Removed	Oral Health
183722	Focus Groups	Form and Instruction	Removed	Occupation
182193	Non Participant Components	Form and Instruction	Modified	Informant Interview
182193	Non Participant Components	Form and Instruction	Modified	Questionaire
182192	Participant Telephone Interviews	Form and Instruction	Removed	survey
182192	Participant Telephone Interviews	Form and Instruction	Removed	survey
182192	Participant Telephone Interviews	Form and Instruction	Removed	survey
182192	Participant Telephone Interviews	Form and Instruction	Removed	survey
182192	Participant Telephone Interviews	Form and Instruction	Removed	survey
182192	Participant Telephone Interviews	Form and Instruction	Removed	Informant
182192	Participant Telephone Interviews	Form and Instruction	Removed	Recall
182191	Clinic Questionaires	Form and Instruction	Removed	survey
182191	Clinic Questionaires	Form and Instruction	Removed	survey
182191	Clinic Questionaires	Form and Instruction	Removed	Well Being
182191	Clinic Questionaires	Form and Instruction	Removed	Weight History
182191	Clinic Questionaires	Form and Instruction	Removed	Tobacco Use
182191	Clinic Questionaires	Form and Instruction	Removed	Social Cultural
182191	Clinic Questionaires	Form and Instruction	Removed	Sleep
182191	Clinic Questionaires	Form and Instruction	Removed	SF 12
182191	Clinic Questionaires	Form and Instruction	Removed	Respiratory
182191	Clinic Questionaires	Form and Instruction	Removed	Physical Activity
182191	Clinic Questionaires	Form and Instruction	Removed	Oral Health
182191	Clinic Questionaires	Form and Instruction	Removed	Occupation
182191	Clinic Questionaires	Form and Instruction	Removed	Neuro
182191	Clinic Questionaires	Form and Instruction	Removed	Medication Use
182191	Clinic Questionaires	Form and Instruction	Removed	Medical History
182191	Clinic Questionaires	Form and Instruction	Removed	Informed Consent
182191	Clinic Questionaires	Form and Instruction	Removed	Hearing Exam
182191	Clinic Questionaires	Form and Instruction	Removed	Health Care Use
182191	Clinic Questionaires	Form and Instruction	Removed	Economic
182191	Clinic Questionaires	Form and Instruction	Removed	Dietary Behavior
182191	Clinic Questionaires	Form and Instruction	Removed	Dietary Recall and Supplement Use
182191	Clinic Questionaires	Form and Instruction	Removed	Alcohol Use
182190	Clinic Exam Procedures	Form and Instruction	Removed	Well Being
182190	Clinic Exam Procedures	Form and Instruction	Removed	Weight History
182190	Clinic Exam Procedures	Form and Instruction	Removed	Tobacco Use
182190	Clinic Exam Procedures	Form and Instruction	Removed	Social Cultural
182190	Clinic Exam Procedures	Form and Instruction	Removed	Sleep
182190	Clinic Exam Procedures	Form and Instruction	Removed	SF 12
182190	Clinic Exam Procedures	Form and Instruction	Removed	Respiratory
182190	Clinic Exam Procedures	Form and Instruction	Removed	Physical Activity
182190	Clinic Exam Procedures	Form and Instruction	Removed	Personal Information
182190	Clinic Exam Procedures	Form and Instruction	Removed	Oral Health
182190	Clinic Exam Procedures	Form and Instruction	Removed	Neuro
182190	Clinic Exam Procedures	Form and Instruction	Removed	Medication Use
182190	Clinic Exam Procedures	Form and Instruction	Removed	Medical History
182190	Clinic Exam Procedures	Form and Instruction	Removed	Informed Consent
182190	Clinic Exam Procedures	Form and Instruction	Removed	Hearing Exam
182190	Clinic Exam Procedures	Form and Instruction	Removed	Health Care Use
182190	Clinic Exam Procedures	Form and Instruction	Removed	Economic
182190	Clinic Exam Procedures	Form and Instruction	Removed	Dietary Behavior
182190	Clinic Exam Procedures	Form and Instruction	Removed	Dietary Recall and Supplement Use
182190	Clinic Exam Procedures	Form and Instruction	Removed	Alcohol Use
182190	Clinic Exam Procedures	Form and Instruction	Removed	Occupation
182189	Participants Follow-up Year 2	Form	Modified	Food Propensity
182189	Participants Follow-up Year 2	Form and Instruction	Modified	Interview
182188	Participants Follow-up Year 1	Form and Instruction	Modified	Interview

ICR Details

OMB Control No: 0925-0584	ICR Reference No: 201110-0925-002
Status: Historical Active	Previous ICR Reference No: 200901-0925-003
Agency/Subagency: HHS/NIH	Agency Tracking No:
Title: The Hispanic Community Health Study/ Study of Latinos (HCHS/SOL)(NHLBI)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 12/12/2011
Retrieve Notice of Action (NOA)	Date Received in OIRA: 10/24/2011
Terms of Clearance: Previous terms of clearance continue: NIH shall exercise caution in reporting study results and will disclose all study limitations when such results are publicly disclosed, particularly concerning the cross-sectional components of this study (e.g. the inability of this study to rigorously assess differences by country of origin within the 4 study sites due to geographical clustering by country of origin, etc.).

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2014	36 Months From Approved	03/31/2012
Responses	17,284	0	66,640
Time Burden (Hours)	5,309	0	48,114
Cost Burden (Dollars)	0	0	0

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Abstract: This project seeks to determine the prevalence of risk factors for cardiovascular disease among Hispanics living in the U.S. and their relationship to cardiovascular morbidity and mortality.

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Authorizing Statute(s): US Code: 42 USC 285b-3 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 48872	08/09/2011
30-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 64357	10/18/2011
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 4

table that charts list of burden

IC Title	Form No.	Form Name
Clinic Exam Procedures	1, 2, 3, 4, 8, 5, 6, 7, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21	Alcohol Use ,   Dietary Recall and Supplement Use ,   Dietary Behavior ,   Economic ,   Health Care Use ,   Hearing Exam ,   Informed Consent ,   Medical History ,   Medication Use ,   Neuro ,   Occupation ,   Oral Health ,   Personal Information ,   Physical Activity ,   Respiratory ,   SF 12 ,   Sleep ,   Social Cultural ,   Tobacco Use ,   Weight History ,   Well Being
Clinic Questionaires	8, 9, 10, 11, 12, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 3, 5, 6, 7, 4, 1, 2	Alcohol Use ,   Dietary Recall and Supplement Use ,   Dietary Behavior ,   Economic ,   Health Care Use ,   Hearing Exam ,   Informed Consent ,   Medical History ,   Medication Use ,   Neuro ,   Occupation ,   Oral Health ,   Physical Activity ,   Respiratory ,   SF 12 ,   Sleep ,   Social Cultural ,   Tobacco Use ,   Weight History ,   Well Being ,   survey ,   survey
Focus Groups	11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21	Occupation ,   Oral Health ,   Personal Information ,   Physical Activity ,   Respiratory ,   SF12 ,   Sleep ,   Social Cultural ,   Tobacco Use ,   Weight History ,   Well Being
Food Propensity	1	survey
Non Participant Components	1, 2	Questionaire ,   Informant Interview
Participant Telephone Interviews	1, 3, 2, 5, 6, 4, 7	Recall ,   Informant ,   survey ,   survey ,   survey ,   survey ,   survey
Participants Follow-up Year 1	1	Interview
Participants Follow-up Year 2	2, 1	Interview ,   Food Propensity
Participants Follow-up Year 3 to 6	3, 4, 5, 6	Interview ,   Interview ,   Interview ,   Interview

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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	17,284	66,640	0	-49,356	0	0
Annual Time Burden (Hours)	5,309	48,114	0	-42,805	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: Yes

Burden Reduction Due to: Changing Forms

Short Statement: With this modification that covers continued annual follow-up of participants, the overall burden hours requested have been reduced to a total of 5,309 hours.

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Annual Cost to Federal Government: $10,561,179

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: 10/24/2011

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