Health Status Questionnaire (HSQ) for PLCO

Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial (PLCO) (NCI)

Documents and Forms

Document Name Document Type
Form 3B Health Status Questionnaire (HSQ) for PLCO Form and Instruction
3A Health Status Questionnaire (Male-HSQ) Attach_03A_HSQ-Male9_24_12.doc Form and Instruction
3B Health Status Questionnaire (Female-HSQ) Attach_03B_HSQ-Female9_24_12.doc Form and Instruction

Information Collection (IC) Details

IC Title:	Health Status Questionnaire (HSQ) for PLCO	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Removed

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	3B	Health Status Questionnaire (Female-HSQ)	Attach_03B_HSQ-Female9_24_12.doc		No	No	Printable Only
Form and Instruction	3A	Health Status Questionnaire (Male-HSQ)	Attach_03A_HSQ-Male9_24_12.doc		No	No	Printable Only

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title: 09-25-0200, "Clinical, Basic and Population-based Research Studies of the National Institutes of Health (NIH), HHS/NIH/OD"	FR Citation: 67 FR 60776

Number of Respondents: 2,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	-2,000	2,000
Annual IC Time Burden (Hours)	-167	167
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.