Information Collection Request

Agricultural Health Study: A Prospective Cohort Study of Cancer and Other Diseases Among Men and Women in Agriculture (NCI)

ICR 201302-0925-004 · OMB 0925-0406 · Historical Active

Forms and Documents

Forms and supporting documents for this ICR
DocumentTypeStatusAvailability
Form 8 CAWI-CATI Form and Instruction Modified Available
Form 9 Paper and Pencil Form and Instruction Modified Available
Form 6 Paper/pen, CAWI or CATI Form and Instruction Modified Available
Form 7 CATI Form and Instruction Modified Available
Form 17 Paper-Pen Proxy Form and Instruction New Available
Form 16 CAWI-CATI Proxy Form and Instruction New Available
Form 15 CATI Proxy Form and Instruction New Available
Form 14 CAWI Proxy Form and Instruction New Available
Form 5 BEEA Home Visit CAPI, Blood, & Urine x 3 Form and Instruction Modified Available
Form 3 BEEA North Carolina Schedule PostApp Visit Script Form and Instruction Modified Available
Form 2 BEEA Iowa Schedule PostApp Visit Script Form and Instruction Modified Available
Form 1 BEEA Previsit Reminder Script Form and Instruction Modified Available
Form 3 BEEA Home Visit CAPI, Blood, & Urine x 1 Form and Instruction Modified Available
Form 3 CATI Eligibility Script_Recently Exposed Respondents Form and Instruction Modified Available
Form 2 CATI Eligibility Script_Randomly Selected Respondents Form and Instruction Modified Available
Form 4 Damaged or Missing Buccal Cell Sample Call Script Form and Instruction Modified Available
Form 2 Reminder Call Script for North Carolina Buccal Cell Respondents Form and Instruction Modified Available
Form 3 Missing Buccal Cell Consent Forms Call Script Form and Instruction Modified Available
Form 1 Reminder Call Script for Iowa Buccal Cell Respondents Form and Instruction Modified Available
Form 13 Paper/Pen Form and Instruction Modified Available
Form 11 CATI Form and Instruction Modified Available
Form 10 CAWI Form and Instruction Modified Available
Form 12 CAWI-CATI Form and Instruction Modified Available
Supporting State B_1107012.docx Supporting Statement B Uploaded 2013-02-08 Available
Attachment 28_AHS_PrivacyImpactAssessments.pdf Supplementary Document Uploaded 2013-02-05 Available
Attachment 27_PhaseIV_HFUP_FAQs_CAWI_CATI.docx Supplementary Document Uploaded 2013-02-05 Available
Attachment 24_Phase_IV_HFUP_Letters.pdf Supplementary Document Uploaded 2013-02-05 Available
Attachment 23_Phase_IV_HFUP_IRB_Appr_Signature_Pages.pdf Supplementary Document Uploaded 2013-02-05 Available
Attachment 22_BEEA_Objectives.doc Supplementary Document Uploaded 2013-02-05 Available
Attachment 18_BEEA_Consent_Forms.pdf Supplementary Document Uploaded 2013-02-05 Available
Attachment 17_BEEA_Letters.pdf Supplementary Document Uploaded 2013-02-05 Available
Attachment 16_Phase_IV_Buccal_Cell_Collection_Information.pdf Supplementary Document Uploaded 2013-02-05 Available
Attachment 15_Phase_IV_Buccal_Consents.docx Supplementary Document Uploaded 2013-02-05 Available
Attachment 14_Phase_IV_Buccal_Cell_Pre-Contact_Letters.pdf Supplementary Document Uploaded 2013-02-05 Available
Attachment 13_BEEA_IRB_Approval_Signature_Pages.pdf Supplementary Document Uploaded 2013-02-05 Available
Attachment 12_Phase_IV_Buccal_Cell_IRB_Approval_Signature_Pages.pdf Supplementary Document Uploaded 2013-02-05 Available
Attachment 11_BEEA_FAQs.pdf Supplementary Document Uploaded 2013-02-05 Available
Attachment 08_STARS_AHS_Confidentiality_Agreement.pdf Supplementary Document Uploaded 2013-02-05 Available
Attachment 07_Contractor_Confidentialiy_Agreement.dot Supplementary Document Uploaded 2013-02-05 Available
Attachment 06_ NIH_Privacy_Act_Memo.pdf Supplementary Document Uploaded 2013-02-05 Available
Attachment 05_Certificate_Of_Confidentiality_NCI-02-028A.pdf Supplementary Document Uploaded 2013-02-05 Available
Attachment 04_NAP_Members_Consultants.doc Supplementary Document Uploaded 2013-02-05 Available
Attachment 03_AGRICOH_Steering_Committee_Mbr_2011.pdf Supplementary Document Uploaded 2013-02-05 Available
Attachment 02_Bibliography.docx Supplementary Document Uploaded 2013-02-05 Available
Attachment 01_List_Of_Attachments_2012.docx Supplementary Document Uploaded 2013-02-05 Available
Cover Memo_Ag Health_12132012_FINAL.docx Supplementary Document Uploaded 2013-02-05 Available
Attachment 09-1_Phase_IV_Initial_Script_Consent_Buccal_Cell.docx Supplementary Document Uploaded 2013-02-06 Repair queued
Supporting State A_1102012.docx Supporting Statement A Uploaded 2013-02-08 Available

IC Document Collections

Information collection document groups
IC IDCollectionTypeStatusForm
7302 Attachment 25: Paper/pen, CAWI or CATI Instruments for Private Applicators for AHS Form and Instruction ModifiedCAWI-CATI
7302 Attachment 25: Paper/pen, CAWI or CATI Instruments for Private Applicators for AHS Form and Instruction ModifiedPaper and Pencil
7302 Attachment 25: Paper/pen, CAWI or CATI Instruments for Private Applicators for AHS Form and Instruction ModifiedPaper/pen, CAWI or CATI
7302 Attachment 25: Paper/pen, CAWI or CATI Instruments for Private Applicators for AHS Form and Instruction ModifiedCATI
205828 Attachment 26: Paper/pen, CAWI, and CATI for Proxy for AHS Form and Instruction NewPaper-Pen Proxy
205828 Attachment 26: Paper/pen, CAWI, and CATI for Proxy for AHS Form and Instruction NewCAWI-CATI Proxy
205828 Attachment 26: Paper/pen, CAWI, and CATI for Proxy for AHS Form and Instruction NewCATI Proxy
205828 Attachment 26: Paper/pen, CAWI, and CATI for Proxy for AHS Form and Instruction NewCAWI Proxy
192872 Attachment 19: BEEA Home Visit CAPI, Blood, & Urine x 3 Form and Instruction ModifiedBEEA Home Visit CAPI, Blood, & Urine x 3
192871 Attachment 10: BEEA Schedule Home Visit Scripts for AHS Form and Instruction ModifiedBEEA North Carolina Schedule PostApp Visit Script
192871 Attachment 10: BEEA Schedule Home Visit Scripts for AHS Form and Instruction ModifiedBEEA Iowa Schedule PostApp Visit Script
192871 Attachment 10: BEEA Schedule Home Visit Scripts for AHS Form and Instruction ModifiedBEEA Previsit Reminder Script
192870 Attachment 19: BEEA Home Visit CAPI, Blood, & Urine x 1 for AHS Form and Instruction ModifiedBEEA Home Visit CAPI, Blood, & Urine x 1
192869 Attachment 20 or 21: BEEA CATI Screener for AHS Form and Instruction ModifiedCATI Eligibility Script_Recently Exposed Respondents
192869 Attachment 20 or 21: BEEA CATI Screener for AHS Form and Instruction ModifiedCATI Eligibility Script_Randomly Selected Respondents
192868 Attachment 9: Reminder, Missing or Damaged Scripts for AHS Form and Instruction ModifiedDamaged or Missing Buccal Cell Sample Call Script
192868 Attachment 9: Reminder, Missing or Damaged Scripts for AHS Form and Instruction ModifiedReminder Call Script for North Carolina Buccal Cell Respondents
192868 Attachment 9: Reminder, Missing or Damaged Scripts for AHS Form and Instruction ModifiedMissing Buccal Cell Consent Forms Call Script
192868 Attachment 9: Reminder, Missing or Damaged Scripts for AHS Form and Instruction ModifiedReminder Call Script for Iowa Buccal Cell Respondents
185933 Attachment 25: Paper/pen, CAWI or CATI for Spouses for AHS Form and Instruction ModifiedPaper/Pen
185933 Attachment 25: Paper/pen, CAWI or CATI for Spouses for AHS Form and Instruction ModifiedCATI
185933 Attachment 25: Paper/pen, CAWI or CATI for Spouses for AHS Form and Instruction ModifiedCAWI
185933 Attachment 25: Paper/pen, CAWI or CATI for Spouses for AHS Form and Instruction ModifiedCAWI-CATI

ICR Details

Reginfo record details
table that charts list comparision
  Inventory as of this Action Requested Previously Approved
04/30/2016 36 Months From Approved 05/31/2013
25,551 0 1,780
10,465 0 550
0 0 0





Reginfo record details
8
table that charts list of burden
IC Title Form No. Form Name
Attachment 10: BEEA Schedule Home Visit Scripts for AHS 2, 1, 3 ,   ,  
Attachment 19: BEEA Home Visit CAPI, Blood, & Urine x 3 5
Attachment 19: BEEA Home Visit CAPI, Blood, & Urine x 1 for AHS 3
Attachment 20 or 21: BEEA CATI Screener for AHS 2, 3 ,  
Attachment 25: Paper/pen, CAWI or CATI Instruments for Private Applicators for AHS 7, 6, 9, 8 ,   ,   ,  
Attachment 25: Paper/pen, CAWI or CATI for Spouses for AHS 12, 10, 11, 13 ,   ,   ,  
Attachment 26: Paper/pen, CAWI, and CATI for Proxy for AHS 15, 16, 17, 14 ,   ,   ,  
Attachment 9: Reminder, Missing or Damaged Scripts for AHS 1, 3, 2, 4 ,   ,   ,  

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 25,551 1,780 0 23,771 0 0
Annual Time Burden (Hours) 10,465 550 0 9,915 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0


Reginfo record details
  No