3 Attachment 3C Updated Screener and Core Questionnaire Ch

AsiaLymph Study

Screener and Questionnaire

Screener

OMB #: 0925-0654

Expiration date: 10/31/2015

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.

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’

Questionnaire

OMB #: 0925-0654

Expiration date: 10/31/2015

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.

Residence

Residence

Start Year

End Year

Longest Adult Residence Address #1

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