Form 14 CAWI Proxy

AHS_PhIV_AU_ScrnShots_20120829.docx
Attachment 26.1: PhaseIV Health Follow-up CAWI Proxy Introductory Interview Script

OMB No.: 0925-0406
Expiration Date: xx/xx/2016
Collection of this information is authorized by The Public Health Service Act (42 USC 285l). Rights of study participants are protected by The Privacy
Act of 1974. Participation is voluntary, and there are no penalties for not participating or withdrawing from the study at any time. Refusal to participate
will not affect your benefits in any way. The information collected in this study will be kept private to the extent provided by law. Names and other
identifiers will not appear in any report of the study. Information provided will be combined for all study participants and reported as summaries. You
are being contacted by mail to complete this online health follow-up survey on behalf of the Agricultural Health Study cohort member because
continued involvement can help us learn more about how agricultural and environmental factors may affect the health of farmers and their families.
Public reporting burden for this collection of information is estimated to average 10 - 15 minutes per response, including the time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.
An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a
currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including
suggestions for reducing this burden to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA
(0925-0406). Do not return the completed form to this address.

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