Information Collection

Clinic Visit 1

IC 203350 under ICR 201301-0925-001 · OMB 0925-0671.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1.1 Clinic Visit 1	Form and Instruction
1.1 Survey Attach 2. Screening Tool.docx	Form and Instruction
1.2 Form Attach 4. Participant Contact Information Sheet.docx	Form
1.4 Survey Attach 7.Visit 1 Stress Questionnaire.docx	Form and Instruction
1.5 Survey Attach 10. SLES Checklist.pdf	Form and Instruction
1.3 Attach 6. Demographic and Health Survey Attach 6. Demographic and Health Survey.docx	Form
Attach 15. Study Visit 1 Blood Requisition Form.docx Attach 15. Study Visit 1 Blood Requisition Form	IC Document
Attach 17. Visit 1 Blood Processing Protocol.doc Attach 17. Visit 1 Blood Processing Protocol	IC Document
Attach 14. Study Hair Collection Protocol.docx Attach 14. Study Hair Collection Protocol	IC Document

IC Title:

Clinic Visit 1

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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	1.1	Survey	Attach 2. Screening Tool.docx	Yes	Yes	Fillable Printable
Form	1.2	Form	Attach 4. Participant Contact Information Sheet.docx	Yes	Yes	Paper Only
Form and Instruction	1.4	Survey	Attach 7.Visit 1 Stress Questionnaire.docx	Yes	Yes	Paper Only
Form and Instruction	1.5	Survey	Attach 10. SLES Checklist.pdf	Yes	Yes	Paper Only
Form	1.3	Attach 6. Demographic and Health Survey	Attach 6. Demographic and Health Survey.docx	Yes	Yes	Paper Only

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
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	700	700
Annual IC Time Burden (Hours)	972	972
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attach 15. Study Visit 1 Blood Requisition Form	Attach 15. Study Visit 1 Blood Requisition Form.docx	12/06/2012
Attach 17. Visit 1 Blood Processing Protocol	Attach 17. Visit 1 Blood Processing Protocol.doc	12/06/2012
Attach 14. Study Hair Collection Protocol	Attach 14. Study Hair Collection Protocol.docx	12/06/2012

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