3C Screener and Core Questionnaire-Chengdu (English)

AsiaLymph Study
Screener and Questionnaire

Screener
OMB #: 0925-0654
Expiration date: 09/30/2012
Public reporting for this collection of information is estimated to average 5 minutes per response,
including the time for reviewing instructions, searching existing data sources, gathering and
maintaining the data needed, and completing and reviewing the collection of information. An
agency may not conduct or sponsor, and a person is not required to respond to, a collection
of information unless it displays a currently valid OMB control number. Send comments
regarding this burden estimate or any other aspect of this collection of information, including
suggestions for reducing this burden, to: NIH, Project Clearance Branch, 6705 Rockledge Drive,
MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0654). Do not return the completed
form to this address.

1

Have you lived in this general area for at least
15 years at anytime in your life?
Note: The general area refers to all areas listed
in the previous question except ‘any other
area’

2

Questionnaire

OMB #: 0925-0654
Expiration date: 09/30/2012
Public reporting for this collection of information is estimated to average 70 minutes per response,
including the time for reviewing instructions, searching existing data sources, gathering and
maintaining the data needed, and completing and reviewing the collection of information. An
agency may not conduct or sponsor, and a person is not required to respond to, a collection
of information unless it displays a currently valid OMB control number. Send comments
regarding this burden estimate or any other aspect of this collection of information, including
suggestions for reducing this burden, to: NIH, Project Clearance Branch, 6705 Rockledge Drive,
MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0654). Do not return the completed
form to this address.

3

If No (0) Siblings,
Go To 1C.1

4

If „None‟ is selected,
Go to 1C.3

If File Typeapplication/pdfFile TitleA MULTI- CENTER INTERNATIONAL HOSPITAL-BASEDAuthorCathy SerrinFile Modified2012-08-18File Created2012-08-18