Information Collection

Patient Screener, Core & Occupational Exposure Questionnaires_AsiaLymph (Attachments 3, 4 & 5)

IC 201512 under ICR 201203-0925-003 · OMB 0925-0654.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0654 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Patient Screener, Core & Occupational Exposure Questionnaires_AsiaLymph (Attachments 3, 4 & 5)	Form and Instruction
1 Screener and Core Questionnaire AsiaLymph Attach 3 - Screener_and_Core_questionnaire.pdf	Form and Instruction
2 Occupational Exposure Qx (examples) Attach 4 - Occupational_Job_Modules-_examples revised 2-26-12.docx	Form and Instruction
3 Occupational Exposure Qx (complete set) Attach 5 - Occupational_Job_Modules_-_complete_set revised 2-26-12.docx	Form and Instruction

IC Title:

Patient Screener, Core & Occupational Exposure Questionnaires_AsiaLymph (Attachments 3, 4 & 5)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	1	Screener and Core Questionnaire AsiaLymph	Attach 3 - Screener_and_Core_questionnaire.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	2	Occupational Exposure Qx (examples)	Attach 4 - Occupational_Job_Modules-_examples revised 2-26-12.docx	Yes	Yes	Fillable Fileable
Form and Instruction	3	Occupational Exposure Qx (complete set)	Attach 5 - Occupational_Job_Modules_-_complete_set revised 2-26-12.docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 5,300

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	5,300	5,300
Annual IC Time Burden (Hours)	4,108	4,108
Annual IC Cost Burden (Dollars)	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.