The Hispanic Community Health Study/ Study of Latinos (HCHS/SOL)(NHLBI)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 1 PQE-Physician Interview	Form and Instruction	New	Available
Form 1 IIE Informant Interview Deaths	Form and Instruction	New	Available
Form 1 AFU-Years7-11 Annual Followup English	Form and Instruction	New	Available
Form 1 AFU-Years 7-11 Annual Followup English	Form and Instruction	New	Available
Form 1 AFU- Years 7-11 Annual Followup English	Form and Instruction	New	Available
Form 1 AFU-Years 7-11 Annual followup English	Form and Instruction	New	Repair queued
Form 1 AFU-Years7-11 Annual Followup English	Form and Instruction	New	Available
Form 1 AFU year 6 Annual followup English	Form and Instruction	New	Available
Form 1 AFU-Year 5 Annual Followup English	Form and Instruction	New	Available
Form 1 AFU Year 4 English	Form and Instruction	New	Available
Form 1 AFU Year 3	Form and Instruction	New	Available
Form 1 Participant Feedback	Form and Instruction	New	Available
Form 1 Alcohol Use	Form and Instruction	New	Available
Form 1 Tobacco	Form and Instruction	New	Available
Form 1 MSE-Medication Use Survey -Eng	Form and Instruction	New	Available
Form 1 Well Being	Form and Instruction	New	Available
Form 1 Acculturation Questionnaire	Form and Instruction	New	Available
Form 1 Social Support	Form and Instruction	New	Available
Form 1 FCE-Family Cohesion-Eng	Form and Instruction	New	Available
Form 1 STE-Chronic Stress-Eng	Form and Instruction	New	Available
Form 1 HCE-HealthCare-Eng	Form and Instruction	New	Available
Form 1 SEE-Socio Econonic Status-Occup-Eng	Form and Instruction	New	Available
Form 1 PCE-Pregnancy Complications Hx - Eng	Form and Instruction	New	Available
Form 1 RME-Repro and Medical History-Eng	Form and Instruction	New	Available
Form 1 MHE-Personal Medical History-Eng	Form and Instruction	New	Available
Form 1 BIO-Biospecimen Collection	Form and Instruction	New	Available
Form 1 Echocardiography Manual	Form and Instruction	New	Available
Form 1 SBP-Sitting Blood Pressure	Form and Instruction	New	Available
Form 1 BIO-Biospecimen Collection	Form and Instruction	New	Available
Form 1 BIO-Biospecimen Collection	Form and Instruction	New	Available
Form 1 ANT-Anthropometry	Form and Instruction	New	Available
Form 1 IDE-Personal Identifiers-Eng	Form and Instruction	New	Available
Form 1 BIO-Biospecimen Collection	Form and Instruction	New	Available
Form 1 PSE-Participant Safety Screen	Form and Instruction	New	Available
Form 1 PDE-Participant Disability Screen Eng	Form and Instruction	New	Available
Form 1 SOL IC English	Form and Instruction	New	Available
Form 6 Interview	Form and Instruction	Removed	Available
Form 5 Interview	Form and Instruction	Removed	Available
Form 4 Interview	Form and Instruction	Removed	Available
Form 3 Interview	Form and Instruction	Removed	Available
Form 2 Informant Interview	Form and Instruction	Removed	Available
Form 1 Questionaire	Form and Instruction	Removed	Available
Form 1 Food Propensity	Form	Removed	Available
Form 2 Interview	Form and Instruction	Removed	Available
Form 1 ELE-Participant eligibility - billingual	Form and Instruction	Modified	Available
Appendix 20 Sources of Questionnaires and Protocols FINAL.doc	Supplementary Document	Uploaded 2014-06-27	Available
Appendix 19 - Example of QXQ.pdf	Supplementary Document	Uploaded 2014-06-27	Available
HCHS SOL Supporting Statement A 08262014.docx	Supporting Statement A	Uploaded 2014-08-28	Available
San Diego Talavera_1586091_SOL Visit 2_New Approval_Minimal Risk_Dec 10 2013mtg.pdf	Supplementary Document	Uploaded 2014-06-25	Available
Miami Schneiderman HCHS Visit 2 IRB approval letter_01082014.pdf	Supplementary Document	Uploaded 2014-06-25	Available
Chicago Daviglus HCHS Visit 2 UIC IRB Approval 20131261-79111-1.pdf	Supplementary Document	Uploaded 2014-06-25	Available
Bronx Kaplan HCHS Visit 2 IRB Approval.pdf	Supplementary Document	Uploaded 2014-06-25	Available
SALUD SOLNEWSLETTER_Vol6No2_Bronx_ENG SPA FINAL_TVC_Bronx.pdf	Supplementary Document	Uploaded 2014-06-25	Available
Participant Booklet National Alliance 2014.pdf	Supplementary Document	Uploaded 2014-06-25	Available
Final pdf NHLBI-HCHSSOL-Spanish-508Rev2-FY14.pdf	Supplementary Document	Uploaded 2014-06-25	Available
Final pdf NHLBI-HCHSSOL-English-508Rev2-FY14.pdf	Supplementary Document	Uploaded 2014-06-25	Available
JAMA Factsheet FINAL SD Eng Span BackFront.pdf	Supplementary Document	Uploaded 2014-06-25	Available
UNC HCHS Coord Center IRB Approval Notice 2013-2014.pdf	Supplementary Document	Uploaded 2014-06-25	Available
Appendix 13 UNC CC Privacy Policy.pdf	Supplementary Document	Uploaded 2014-06-12	Available
Appendix 12 - Privacy Act System Notice.pdf	Supplementary Document	Uploaded 2014-06-12	Available
SOL IC Spanish FINAL 27 Dec 2013.pdf	Supplementary Document	Uploaded 2014-06-12	Available
SOL IC English FINAL 27 Dec 2013.pdf	Supplementary Document	Uploaded 2014-06-12	Available
San Diego HIPPA Form SOL Visit 2 English 1-17-2014.pdf	Supplementary Document	Uploaded 2014-06-12	Available
San Diego HIPAA Form SOL Visit 2 Spanish-1-17-14.pdf	Supplementary Document	Uploaded 2014-06-12	Available
Miami HCHS Visit 2 HIPAA FormB-Spanish.pdf	Supplementary Document	Uploaded 2014-06-12	Available
Miami HCHS Visit 2 HIPAA FormB-English.pdf	Supplementary Document	Uploaded 2014-06-12	Available
Chicago HCHS-SOL-Visit 2 HIPAA English20140103.pdf	Supplementary Document	Uploaded 2014-06-12	Available
Chicago HCHS-SOL Visit 2 HIPPA Spanish.pdf	Supplementary Document	Uploaded 2014-06-12	Available
Bronx HCHS Updated Spanish HIPAA.pdf	Supplementary Document	Uploaded 2014-06-12	Available
Bronx HCHS Updated English HIPAA .pdf	Supplementary Document	Uploaded 2014-06-12	Available
Kost Clinical Research Experience.pdf	Supplementary Document	Uploaded 2014-06-11	Available
Grady payment.pdf	Supplementary Document	Uploaded 2014-06-11	Available
Grady incentives.pdf	Supplementary Document	Uploaded 2014-06-11	Available
Appendix 8 - HCHS OSMB Minutes 8 Nov 2013.docx	Supplementary Document	Uploaded 2014-06-11	Available
Appendix 7 - NHLBI Advisory Council June 2011 Roster.docx	Supplementary Document	Uploaded 2014-06-11	Available
Appendix 6 - NHLBI Council Minutes June 2011.docx	Supplementary Document	Uploaded 2014-06-11	Available
Appendix 5 - Future Research Opportunities HCHS SOL 2010.docx	Supplementary Document	Uploaded 2014-06-11	Available
Appendix 4 - Epidemiologic Research in Hispanic Populations 2003.docx	Supplementary Document	Uploaded 2014-06-11	Available
Appendix 3 - Comparison Visit 1 and Visit 2 HCHS SOL.docx	Supplementary Document	Uploaded 2014-06-11	Available
Appendix 2 - NHLBI Legislative Mandate.pdf	Supplementary Document	Uploaded 2014-06-11	Available
Appendix 1c Sorlie et al Design and Implementation SOL.pdf	Supplementary Document	Uploaded 2014-06-11	Available
Appendix 1b LaVange et al Sampling Design SOL.pdf	Supplementary Document	Uploaded 2014-06-11	Available
Appendix 1a Daviglus et al Prevalence of CVD risk Factors.pdf	Supplementary Document	Uploaded 2014-06-11	Available
HCHS SOL Supporting Statement B FINAL May2014.docx	Supporting Statement B	Uploaded 2014-06-09	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
212138	PQE Hospitalization records/physician interview	Form and Instruction	New	PQE-Physician Interview
212135	IIE-Informant Interview Deaths - Eng	Form and Instruction	New	IIE Informant Interview Deaths
211993	AFU Year 11	Form and Instruction	New	AFU-Years7-11 Annual Followup English
211992	AFU Year 10	Form and Instruction	New	AFU-Years 7-11 Annual Followup English
211991	AFU Year 9	Form and Instruction	New	AFU- Years 7-11 Annual Followup English
211990	AFU Year 8	Form and Instruction	New	AFU-Years 7-11 Annual followup English
211989	AFU Year 7	Form and Instruction	New	AFU-Years7-11 Annual Followup English
211988	AFU Year 6	Form and Instruction	New	AFU year 6 Annual followup English
211987	AFU Year 5	Form and Instruction	New	AFU-Year 5 Annual Followup English
211986	AFU Year 4	Form and Instruction	New	AFU Year 4 English
211985	AFU Year 3	Form and Instruction	New	AFU Year 3
211984	Participant Feedback	Form and Instruction	New	Participant Feedback
211983	Alcohol Use	Form and Instruction	New	Alcohol Use
211981	Tobacco Use	Form and Instruction	New	Tobacco
211980	Abbreviated Medication Use	Form and Instruction	New	MSE-Medication Use Survey -Eng
211979	Well Being	Form and Instruction	New	Well Being
211978	Acculturation	Form and Instruction	New	Acculturation Questionnaire
211977	Social Support	Form and Instruction	New	Social Support
211976	Family Cohesion	Form and Instruction	New	FCE-Family Cohesion-Eng
211975	Chronic Stress	Form and Instruction	New	STE-Chronic Stress-Eng
211974	Health Care Access and Utilization	Form and Instruction	New	HCE-HealthCare-Eng
211973	Socio-economic Status - Occupation	Form and Instruction	New	SEE-Socio Econonic Status-Occup-Eng
211972	Pregnancy Complications History	Form and Instruction	New	PCE-Pregnancy Complications Hx - Eng
211971	Reproductive Medical History	Form and Instruction	New	RME-Repro and Medical History-Eng
211970	Personal Medical History	Form and Instruction	New	MHE-Personal Medical History-Eng
211969	2-hour blood draw, snack	Form and Instruction	New	BIO-Biospecimen Collection
211968	Echocardiography	Form and Instruction	New	Echocardiography Manual
211967	Seated BP	Form and Instruction	New	SBP-Sitting Blood Pressure
211966	Determination of blood glucose, OGTT	Form and Instruction	New	BIO-Biospecimen Collection
211965	Determination of fasting & blood draw	Form and Instruction	New	BIO-Biospecimen Collection
211964	Anthropometry	Form and Instruction	New	ANT-Anthropometry
211962	Updated personal information	Form and Instruction	New	IDE-Personal Identifiers-Eng
211961	Change clothes, urine specimen	Form and Instruction	New	BIO-Biospecimen Collection
211960	Participant safety screeing update and routing	Form and Instruction	New	PSE-Participant Safety Screen
211959	Participant disability screening	Form and Instruction	New	PDE-Participant Disability Screen Eng
211917	Reception, informed consent, medical releases	Form and Instruction	New	SOL IC English
199868	Participants Follow-up Year 3 to 6	Form and Instruction	Removed	Interview
199868	Participants Follow-up Year 3 to 6	Form and Instruction	Removed	Interview
199868	Participants Follow-up Year 3 to 6	Form and Instruction	Removed	Interview
199868	Participants Follow-up Year 3 to 6	Form and Instruction	Removed	Interview
182193	Non Participant Components	Form and Instruction	Removed	Informant Interview
182193	Non Participant Components	Form and Instruction	Removed	Questionaire
182189	Participants Follow-up Year 2	Form	Removed	Food Propensity
182189	Participants Follow-up Year 2	Form and Instruction	Removed	Interview
182188	Pre-visit scheduling and safety screening	Form and Instruction	Modified	ELE-Participant eligibility - billingual

ICR Details

OMB Control No: 0925-0584	ICR Reference No: 201406-0925-002
Status: Historical Active	Previous ICR Reference No: 201110-0925-002
Agency/Subagency: HHS/NIH	Agency Tracking No:
Title: The Hispanic Community Health Study/ Study of Latinos (HCHS/SOL)(NHLBI)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 08/29/2014
Retrieve Notice of Action (NOA)	Date Received in OIRA: 07/17/2014
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2017	36 Months From Approved	12/31/2014
Responses	470,709	0	17,284
Time Burden (Hours)	74,386	0	5,309
Cost Burden (Dollars)	0	0	0

---

Abstract: The overall purpose of the continuation of the HCHS/SOL is to estimate the incidence of cardiovascular risk factors and risk factors for other chronic diseases, and their relationship to baseline cardiometabolic and general health profile and to the incidence of cardiovascular events (morbidity), cardiovascular mortality and all-cause mortality in a randomly selected sample of men and women who self-identified as Hispanic, and who represent four different communities in the U.S. The Field Centers are located in San Diego (San Diego State University), Chicago (University of Illinois at Chicago), New York (Albert Einstein Medical College-Montefiore Medical Center), and Miami (University of Miami). Coordination of methods, instruments, training, and data analysis will take place at the University of North Carolina at Chapel Hill. In addition, an Echocardiography Reading Center at Brigham and Women's Hospital will oversee the collection of echocardiographic data and its interpretation and analysis.

---

Authorizing Statute(s): US Code: 42 USC 285b-3 Name of Law: Public Health Service Act
  

Citations for New Statutory Requirements: None

---

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

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 16345	03/25/2014
30-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 41293	07/15/2014
Did the Agency receive public comments on this ICR? Yes

---

Number of Information Collection (IC) in this ICR: 37

table that charts list of burden

IC Title	Form No.	Form Name
2-hour blood draw, snack	1	BIO-Biospecimen Collection
AFU Year 10	1	AFU-Years 7-11 Annual Followup English
AFU Year 11	1	AFU-Years7-11 Annual Followup English
AFU Year 3	1	AFU Year 3
AFU Year 4	1	AFU Year 4 English
AFU Year 5	1	AFU-Year 5 Annual Followup English
AFU Year 6	1	AFU year 6 Annual followup English
AFU Year 7	1	AFU-Years7-11 Annual Followup English
AFU Year 8	1	AFU-Years 7-11 Annual followup English
AFU Year 9	1	AFU- Years 7-11 Annual Followup English
Abbreviated Medication Use	1	MSE-Medication Use Survey -Eng
Acculturation	1	Acculturation Questionnaire
Alcohol Use	1	Alcohol Use
Anthropometry	1	ANT-Anthropometry
Change clothes, urine specimen	1	BIO-Biospecimen Collection
Chronic Stress	1	STE-Chronic Stress-Eng
Determination of blood glucose, OGTT	1	BIO-Biospecimen Collection
Determination of fasting & blood draw	1	BIO-Biospecimen Collection
Echocardiography	1	Echocardiography Manual
Family Cohesion	1	FCE-Family Cohesion-Eng
Health Care Access and Utilization	1	HCE-HealthCare-Eng
IIE-Informant Interview Deaths - Eng	1	IIE Informant Interview Deaths
Non Participant Components	1, 2	Questionaire ,   Informant Interview
PQE Hospitalization records/physician interview	1	PQE-Physician Interview
Participant Feedback	1	Participant Feedback
Participant disability screening	1	PDE-Participant Disability Screen Eng
Participant safety screeing update and routing	1	PSE-Participant Safety Screen
Participants Follow-up Year 2	2, 1	Interview ,   Food Propensity
Participants Follow-up Year 3 to 6	3, 4, 5, 6	Interview ,   Interview ,   Interview ,   Interview
Personal Medical History	1	MHE-Personal Medical History-Eng
Pre-visit scheduling and safety screening	1	ELE-Participant eligibility - billingual
Pregnancy Complications History	1	PCE-Pregnancy Complications Hx - Eng
Reception, informed consent, medical releases	1	SOL IC English
Reproductive Medical History	1	RME-Repro and Medical History-Eng
Seated BP	1	SBP-Sitting Blood Pressure
Social Support	1	Social Support
Socio-economic Status - Occupation	1	SEE-Socio Econonic Status-Occup-Eng
Tobacco Use	1	Tobacco
Updated personal information	1	IDE-Personal Identifiers-Eng
Well Being	1	Well Being

---

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	470,709	17,284	0	453,425	0	0
Annual Time Burden (Hours)	74,386	5,309	0	69,077	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: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: This is a revision of a currently approved information collection request for the second phase of the study, which will consist of a much shorter examination than baseline. Details of the specific changes are detailed in the in summary on page 1. The changes have resulted in a decrease in burden from 48,114 to 30,940.

---

Annual Cost to Federal Government: $11,546,681

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

---

Common Form ICR:  No

---

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: 07/17/2014

---