Information Collection

Health Status Questionnaire (HSQ) for PLCO

IC 186212 under ICR 201504-0925-008 · OMB 0925-0407.

Documents and Forms

Documents and forms in this information collection
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

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Removed

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.