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

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 8 CAWI-CATI	Form and Instruction	Modified	Available
Form 6 Paper/pen, CAWI or CATI	Form and Instruction	Modified	Available
Form 9 Paper and Pencil	Form and Instruction	Modified	Available
Form 7 CATI	Form and Instruction	Modified	Available
Form 3 BEEA Dust Specimen Questionnaire	Form and Instruction	New	Available
Form 2 BEEA Consent Form - Dust	Form and Instruction	New	Available
Form 1 BEEA Show Cards	Form and Instruction	New	Available
Form 16 CAWI-CATI Proxy	Form and Instruction	Modified	Repair queued
Form 14 CAWI Proxy	Form and Instruction	Modified	Available
Form 17 Paper-Pen Proxy	Form and Instruction	Modified	Available
Form 15 CATI Proxy	Form and Instruction	Modified	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	Repair queued
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 1 Attachment 20: BEEA CATI Script	Form and Instruction	Modified	Available
Form 3 CATI Eligibility Script_Recently Exposed 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
0925-0406 Supporting State B_7-2-2013.doc	Supporting Statement B	Uploaded 2013-08-13	Available
0925-0406 Cover Memo_Ag Health_7-2-2013.doc	Supplementary Document	Uploaded 2013-08-13	Available
Attachment 28_AHS_PrivacyImpactAssessments.pdf	Supplementary Document	Uploaded 2013-08-13	Available
Attachment 27_PhaseIV_HFUP_FAQs_CAWI_CATI.docx	Supplementary Document	Uploaded 2013-08-13	Available
Attachment 24_Phase_IV_HFUP_Letters.pdf	Supplementary Document	Uploaded 2013-08-13	Available
Attachment 23_Phase_IV_HFUP_IRB_Appr_Signature_Pages.pdf	Supplementary Document	Uploaded 2013-08-13	Available
Attachment 22-1_BEEA_Objectives_with references_Dust.doc	Supplementary Document	Uploaded 2013-08-13	Available
Attachment 17_BEEA_Letters_Directions_noburdens.pdf	Supplementary Document	Uploaded 2013-08-13	Available
Attachment 16_Phase_IV_Buccal_Cell_Collection_Information.pdf	Supplementary Document	Uploaded 2013-08-13	Available
Attachment 15_Phase_IV_Buccal_Consents.docx	Supplementary Document	Uploaded 2013-08-13	Available
Attachment 14_Phase_IV_Buccal_Cell_Pre-Contact_Letters.pdf	Supplementary Document	Uploaded 2013-08-13	Available
Attachment 13_BEEA_IRB_Approval_Signature_Pages.pdf	Supplementary Document	Uploaded 2013-08-13	Available
Attachment 12_Phase_IV_Buccal_Cell_IRB_Approval_Signature_Pages.pdf	Supplementary Document	Uploaded 2013-08-13	Available
Attachment 11_BEEA_FAQs.pdf	Supplementary Document	Uploaded 2013-08-13	Available
Attachment 08_STARS_AHS_Confidentiality_Agreement.pdf	Supplementary Document	Uploaded 2013-08-13	Available
Attachment 07_Contractor_Confidentialiy_Agreement.dot	Supplementary Document	Uploaded 2013-08-13	Repair queued
Attachment 06_ NIH_Privacy_Act_Memo.pdf	Supplementary Document	Uploaded 2013-08-13	Available
Attachment 05_Certificate_Of_Confidentiality_NCI-02-028A.pdf	Supplementary Document	Uploaded 2013-08-13	Available
Attachment 04_NAP_Members_Consultants.doc	Supplementary Document	Uploaded 2013-08-13	Available
Attachment 03_AGRICOH_Steering_Committee_Mbr_2011.pdf	Supplementary Document	Uploaded 2013-08-13	Available
Attachment 02_Bibliography.docx	Supplementary Document	Uploaded 2013-08-13	Available
Attachment 01_List_Of_Attachments_2013.docx	Supplementary Document	Uploaded 2013-08-13	Available
Attachment 09-1_Phase_IV_Initial_Script_Consent_Buccal_Cell.docx	Supplementary Document	Uploaded 2013-02-06	Available
0925-0406 Supporting State A_7-2-2013.doc	Supporting Statement A	Uploaded 2013-08-13	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
7302	Attachment 25: Paper/pen, CAWI or CATI Instruments for Private Applicators for AHS	Form and Instruction	Modified	CAWI-CATI
7302	Attachment 25: Paper/pen, CAWI or CATI Instruments for Private Applicators for AHS	Form and Instruction	Modified	Paper/pen, CAWI or CATI
7302	Attachment 25: Paper/pen, CAWI or CATI Instruments for Private Applicators for AHS	Form and Instruction	Modified	Paper and Pencil
7302	Attachment 25: Paper/pen, CAWI or CATI Instruments for Private Applicators for AHS	Form and Instruction	Modified	CATI
208235	Attachments: 17.5 -17.6; 18; 22.2 consent forms, show cards, and dust questionnaire	Form and Instruction	New	BEEA Dust Specimen Questionnaire
208235	Attachments: 17.5 -17.6; 18; 22.2 consent forms, show cards, and dust questionnaire	Form and Instruction	New	BEEA Consent Form - Dust
208235	Attachments: 17.5 -17.6; 18; 22.2 consent forms, show cards, and dust questionnaire	Form and Instruction	New	BEEA Show Cards
205828	Attachment 26: Paper/pen, CAWI, and CATI for Proxy for AHS	Form and Instruction	Modified	CAWI-CATI Proxy
205828	Attachment 26: Paper/pen, CAWI, and CATI for Proxy for AHS	Form and Instruction	Modified	CAWI Proxy
205828	Attachment 26: Paper/pen, CAWI, and CATI for Proxy for AHS	Form and Instruction	Modified	Paper-Pen Proxy
205828	Attachment 26: Paper/pen, CAWI, and CATI for Proxy for AHS	Form and Instruction	Modified	CATI Proxy
192872	Attachment 19: BEEA Home Visit CAPI, Blood, amp; Urine x 3	Form and Instruction	Modified	BEEA Home Visit CAPI, Blood, & Urine x 3
192871	Attachment 10: BEEA Schedule Home Visit Scripts for AHS	Form and Instruction	Modified	BEEA North Carolina Schedule PostApp Visit Script
192871	Attachment 10: BEEA Schedule Home Visit Scripts for AHS	Form and Instruction	Modified	BEEA Iowa Schedule PostApp Visit Script
192871	Attachment 10: BEEA Schedule Home Visit Scripts for AHS	Form and Instruction	Modified	BEEA Previsit Reminder Script
192870	Attachment 19: BEEA Home Visit CAPI, Blood, amp; Urine x 1 for AHS	Form and Instruction	Modified	BEEA Home Visit CAPI, Blood, & Urine x 1
192869	Attachment 20 or 21: BEEA CATI Screener for AHS	Form and Instruction	Modified	Attachment 20: BEEA CATI Script
192869	Attachment 20 or 21: BEEA CATI Screener for AHS	Form and Instruction	Modified	CATI Eligibility Script_Recently Exposed Respondents
192868	Attachment 9: Reminder, Missing or Damaged Scripts for AHS	Form and Instruction	Modified	Damaged or Missing Buccal Cell Sample Call Script
192868	Attachment 9: Reminder, Missing or Damaged Scripts for AHS	Form and Instruction	Modified	Reminder Call Script for North Carolina Buccal Cell Respondents
192868	Attachment 9: Reminder, Missing or Damaged Scripts for AHS	Form and Instruction	Modified	Missing Buccal Cell Consent Forms Call Script
192868	Attachment 9: Reminder, Missing or Damaged Scripts for AHS	Form and Instruction	Modified	Reminder Call Script for Iowa Buccal Cell Respondents
185933	Attachment 25: Paper/pen, CAWI or CATI for Spouses for AHS	Form and Instruction	Modified	Paper/Pen
185933	Attachment 25: Paper/pen, CAWI or CATI for Spouses for AHS	Form and Instruction	Modified	CATI
185933	Attachment 25: Paper/pen, CAWI or CATI for Spouses for AHS	Form and Instruction	Modified	CAWI
185933	Attachment 25: Paper/pen, CAWI or CATI for Spouses for AHS	Form and Instruction	Modified	CAWI-CATI

ICR Details

OMB Control No: 0925-0406	ICR Reference No: 201308-0925-001
Status: Historical Active	Previous ICR Reference No: 201302-0925-004
Agency/Subagency: HHS/NIH	Agency Tracking No: 20219
Title: Agricultural Health Study: A Prospective Cohort Study of Cancer and Other Diseases Among Men and Women in Agriculture
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 09/30/2013
Retrieve Notice of Action (NOA)	Date Received in OIRA: 08/15/2013
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2016	36 Months From Approved	04/30/2016
Responses	25,711	0	25,551
Time Burden (Hours)	10,678	0	10,465
Cost Burden (Dollars)	0	0	0

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Abstract: The Agricultural Health Study (AHS) program staff is requesting approval of this revision to add a new dust specimen component to the ongoing Agricultural Health Study (AHS). AHS is a cohort study of 89,568 licensed pesticide applicators (both private and commercial applicators)and the spouses of the private applicators in Iowa and North Carolina that is to be followed for 20 years or more. The primary objective of the AHS study remains to be determination of the health effects resulting from occupational and environmental exposures in agriculture. This revision is to initiate and complete a new dust specimen component as part of the ongoing Study of Biomarkers of Exposures and Effects in Agriculture (BEEA). The dust component will include a brief paper-and-pen questionnaire mailed to the participant in advance of the home visit. At the home visit, the study phlebotomist will collect the participant's disposable vacuum bag (or empty the dust from vacuums without disposable bags). We are using similar procedures to ones that have been employed on other NCI studies to obtain information about the dust specimen and to collect and ship the dust specimen.

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Authorizing Statute(s): US Code: 42 USC 285l Name of Law: Public Health Service Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 23942	04/23/2013
30-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 43215	07/19/2013
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 9

table that charts list of burden

IC Title	Form No.	Form Name
Attachment 10: BEEA Schedule Home Visit Scripts for AHS	1, 2, 3	BEEA Previsit Reminder Script ,   BEEA Iowa Schedule PostApp Visit Script ,   BEEA North Carolina Schedule PostApp Visit Script
Attachment 19: BEEA Home Visit CAPI, Blood, amp; Urine x 3	5	BEEA Home Visit CAPI, Blood, & Urine x 3
Attachment 19: BEEA Home Visit CAPI, Blood, amp; Urine x 1 for AHS	3	BEEA Home Visit CAPI, Blood, & Urine x 1
Attachment 20 or 21: BEEA CATI Screener for AHS	3, 1	CATI Eligibility Script_Recently Exposed Respondents ,   Attachment 20: BEEA CATI Script
Attachment 25: Paper/pen, CAWI or CATI Instruments for Private Applicators for AHS	7, 9, 6, 8	CATI ,   Paper and Pencil ,   Paper/pen, CAWI or CATI ,   CAWI-CATI
Attachment 25: Paper/pen, CAWI or CATI for Spouses for AHS	12, 10, 11, 13	CAWI-CATI ,   CAWI ,   CATI ,   Paper/Pen
Attachment 26: Paper/pen, CAWI, and CATI for Proxy for AHS	15, 17, 14, 16	CATI Proxy ,   Paper-Pen Proxy ,   CAWI Proxy ,   CAWI-CATI Proxy
Attachment 9: Reminder, Missing or Damaged Scripts for AHS	2, 4, 1, 3	Reminder Call Script for Iowa Buccal Cell Respondents ,   Missing Buccal Cell Consent Forms Call Script ,   Reminder Call Script for North Carolina Buccal Cell Respondents ,   Damaged or Missing Buccal Cell Sample Call Script
Attachments: 17.5 -17.6; 18; 22.2 consent forms, show cards, and dust questionnaire	1, 2, 3	BEEA Show Cards ,   BEEA Consent Form - Dust ,   BEEA Dust Specimen Questionnaire

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ICR Summary of Burden

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	25,711	25,551	0	160	0	0
Annual Time Burden (Hours)	10,678	10,465	0	213	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: Collection of dust specimen was added to the data collection.

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Annual Cost to Federal Government: $1,251,372

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 08/15/2013

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