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

A multi-center international hospital-based case-control study of lymphoma in Asia (AsiaLymph) (NCI)

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

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

Information Collection (IC) Details

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:

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 %

	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

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.