Attachments: 17.5 -17.6; 18; 22.2 consent forms, show cards, and dust questionnaire

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

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0406 can be found here:

Documents and Forms

Document Name Document Type
Form 1 Attachments: 17.5 -17.6; 18; 22.2 consent forms, show cards, and dust questionnaire Form and Instruction
1 BEEA Show Cards Attachment 17-5 17-6_BEEA_ShowCards_burden.pdf Form and Instruction
2 BEEA Consent Form - Dust Attachment 18_BEEA_Consent Forms_Dust.pdf Form and Instruction
3 BEEA Dust Specimen Questionnaire Attachment 22-2_Dust Questionnaire_columns.doc Form and Instruction

Information Collection (IC) Details

IC Title:	Attachments: 17.5 -17.6; 18; 22.2 consent forms, show cards, and dust questionnaire	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	1	BEEA Show Cards	Attachment 17-5 17-6_BEEA_ShowCards_burden.pdf	Yes	No	Paper Only
Form and Instruction	2	BEEA Consent Form - Dust	Attachment 18_BEEA_Consent Forms_Dust.pdf	Yes	No	Paper Only
Form and Instruction	3	BEEA Dust Specimen Questionnaire	Attachment 22-2_Dust Questionnaire_columns.doc	Yes	No	Paper Only

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 160	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Farms

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	160	160
Annual IC Time Burden (Hours)	53	53
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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