Information Collection

Questionnaires, Time Diary, Heart Monitoring

IC 203351 under ICR 201207-0925-002 · OMB 0925-0671.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0671 can be found here:

2013-01-04 - New collection (Request for a new OMB Control Number)

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 2.1 Participant Contact Information Sheet Questionnaires, Time Diary, Heart Monitoring	Form and Instruction
Form 2.2 Demographic and Health Survey Questionnaires, Time Diary, Heart Monitoring	Form and Instruction
Form 2.3 Visit 1 Stress Questionnaire Questionnaires, Time Diary, Heart Monitoring	Form and Instruction
Form 2.4 Take Home Packet Questionnaires, Time Diary, Heart Monitoring	Form and Instruction
Form 2.5 Visit 2 Stress Questionnaire Questionnaires, Time Diary, Heart Monitoring	Form and Instruction
Form 2.6 SLES Checklist Questionnaires, Time Diary, Heart Monitoring	Form and Instruction
Attach 22. Electronic Diary Coordinators Manual.doc	Instruction
Attach 23. Actiheart Procedures Coordinators Manual.doc	Instruction
2.1 Participant Contact Information Sheet Attach 4. Participant Contact Information Sheet.docx	Form and Instruction
2.2 Demographic and Health Survey Attach 6. Demographic and Health Survey.docx	Form and Instruction
2.3 Visit 1 Stress Questionnaire Attach 7.Visit 1 Stress Questionnaire.docx	Form and Instruction
2.4 Take Home Packet Attach 8. Take Home Packet.docx	Form and Instruction
2.5 Visit 2 Stress Questionnaire Attach 9. Visit 2 Stress Questionnaire.docx	Form and Instruction
2.6 SLES Checklist Attach 10. SLES Checklist.pdf	Form and Instruction
Attach 5. Enrollment Medical Record Abstraction Form.doc Enrollment Medical Record Abstraction Form	IC Document
Attach 11. Postpartum Abstraction Form.doc Postpartum Abstraction Form	IC Document
Note-to-File - Burden for IC #2.docx Note-to-File - Burden for IC #2	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Questionnaires, Time Diary, Heart Monitoring

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	2.1	Participant Contact Information Sheet	Attach 4. Participant Contact Information Sheet.docx	Yes	Yes	Fillable Printable
Form and Instruction	2.2	Demographic and Health Survey	Attach 6. Demographic and Health Survey.docx	Yes	Yes	Paper Only
Form and Instruction	2.3	Visit 1 Stress Questionnaire	Attach 7.Visit 1 Stress Questionnaire.docx	Yes	Yes	Paper Only
Instruction			Attach 22. Electronic Diary Coordinators Manual.doc	Yes	Yes	Paper Only
Form and Instruction	2.4	Take Home Packet	Attach 8. Take Home Packet.docx	Yes	Yes	Fillable Printable
Form and Instruction	2.5	Visit 2 Stress Questionnaire	Attach 9. Visit 2 Stress Questionnaire.docx	Yes	Yes	Paper Only
Instruction			Attach 23. Actiheart Procedures Coordinators Manual.doc	Yes	Yes	Paper Only
Form and Instruction	2.6	SLES Checklist	Attach 10. SLES Checklist.pdf	Yes	Yes	Fillable Printable

Federal Enterprise Architecture Business Reference Module

Line of Business: General Science and Innovation

Subfunction: Scientific and Technological Research and Innovation

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 700

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	56,000	56,000
Annual IC Time Burden (Hours)	4,736	4,736
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Enrollment Medical Record Abstraction Form	Attach 5. Enrollment Medical Record Abstraction Form.doc	07/17/2012
Postpartum Abstraction Form	Attach 11. Postpartum Abstraction Form.doc	07/17/2012
Note-to-File - Burden for IC #2	Note-to-File - Burden for IC #2.docx	07/17/2012

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.