OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

Patient Screener, Core & Occupational Exposure Questionnaires_AsiaLymph (Attachments 3, 4 & 5)

IC 201512 under ICR 201510-0925-005 · OMB 0925-0654.

Documents and Forms

Documents and forms in this information collection
Document NameDocument Type
Form 3A
Patient Screener, Core & Occupational Exposure Questionnaires_AsiaLymph (Attachments 3, 4 & 5)		 Form and Instruction
3A Screener and Core Questionnaire-Hong Kong (English)
Attach 3A -Screen&CoreQx_HongKong_English.pdf 		Form and Instruction
3B Screener and Core Questionnaire-Hong Kong (Chinese)
Attach 3B -Screen&CoreQx_HongKong_Chinese.pdf 		Form and Instruction
3C Screener and Core Questionnaire-Chengdu (English)
Attach 3C -Screen&CoreQx_Chengdu_English.pdf 		Form and Instruction
3D Screener and Core Questionnaire-Chengdu (Chinese)
Attach 3D -Screen&CoreQx_Chengdu_Chinese.pdf 		Form and Instruction
3E Screener and Core Questionnaire-Taiwan (English)
Attach 3E -Screen&CoreQx_Taiwan_English.pdf 		Form and Instruction
3F Screener and Core Questionnaire-Taiwan (Chinese)
Attach 3F -Screen&CoreQx_Taiwan_Chinese.pdf 		Form and Instruction
3G Screener and Core Questionnaire-Tianjin (English)
Attach 3G -Screen&CoreQx_Tianjin_English.pdf 		Form and Instruction
3H Screener and Core Questionnaire-Tianjin (Chinese)
Attach 3H -Screen&CoreQx_Tianjin_Chinese.pdf 		Form and Instruction
4 Occupational Job Exposure Modules - examples
Attach 4 - Occupational_Job_Modules-_examples revised 2-26-12.docx 		Form and Instruction
5 Occupational Job Exposure Modules - complete set
Attach 5 - Occupational_Job_Modules_-_complete_set revised 2-26-12.docx 		Form and Instruction
3A Screener and Core Questionnaire-Hong Kong (English)
Attach 3A -Screen&CoreQx_HongKong_English.pdf 		Form and Instruction
3B Screener and Core Questionnaire-Hong Kong (Chinese)
Attach 3B -Screen&CoreQx_HongKong_Chinese.pdf 		Form and Instruction
3C Screener and Core Questionnaire-Chengdu (English)
Attach 3C -Screen&CoreQx_Chengdu_English.pdf 		Form and Instruction
3D Screener and Core Questionnaire-Chengdu (Chinese)
Attach 3D -Screen&CoreQx_Chengdu_Chinese.pdf 		Form and Instruction
3E Screener and Core Questionnaire-Taiwan (English)
Attach 3E -Screen&CoreQx_Taiwan_English.pdf 		Form and Instruction
3F Screener and Core Questionnaire-Taiwan (Chinese)
Attach 3F -Screen&CoreQx_Taiwan_Chinese.pdf 		Form and Instruction
3G Screener and Core Questionnaire-Tianjin (English)
Attach 3G -Screen&CoreQx_Tianjin_English.pdf 		Form and Instruction
3H Screener and Core Questionnaire-Tianjin (Chinese)
Attach 3H -Screen&CoreQx_Tianjin_Chinese.pdf 		Form and Instruction
4 Occupational Job Exposure Modules - examples
Attach 4 - Occupational_Job_Modules-_examples revised 2-26-12.docx 		Form and Instruction
5 Occupational Job Exposure Modules - complete set
Attach 5 - Occupational_Job_Modules_-_complete_set revised 2-26-12.docx 		Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

layout table

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 3A Screener and Core Questionnaire-Hong Kong (English) Attach 3A -Screen&CoreQx_HongKong_English.pdf Yes Yes Fillable Fileable
Form and Instruction 3B Screener and Core Questionnaire-Hong Kong (Chinese) Attach 3B -Screen&CoreQx_HongKong_Chinese.pdf Yes Yes Fillable Fileable
Form and Instruction 3C Screener and Core Questionnaire-Chengdu (English) Attach 3C -Screen&CoreQx_Chengdu_English.pdf Yes Yes Fillable Fileable
Form and Instruction 3D Screener and Core Questionnaire-Chengdu (Chinese) Attach 3D -Screen&CoreQx_Chengdu_Chinese.pdf Yes Yes Fillable Fileable
Form and Instruction 3E Screener and Core Questionnaire-Taiwan (English) Attach 3E -Screen&CoreQx_Taiwan_English.pdf Yes Yes Fillable Fileable
Form and Instruction 3F Screener and Core Questionnaire-Taiwan (Chinese) Attach 3F -Screen&CoreQx_Taiwan_Chinese.pdf Yes Yes Fillable Fileable
Form and Instruction 3G Screener and Core Questionnaire-Tianjin (English) Attach 3G -Screen&CoreQx_Tianjin_English.pdf Yes Yes Fillable Fileable
Form and Instruction 3H Screener and Core Questionnaire-Tianjin (Chinese) Attach 3H -Screen&CoreQx_Tianjin_Chinese.pdf Yes Yes Fillable Fileable
Form and Instruction 4 Occupational Job Exposure Modules - examples Attach 4 - Occupational_Job_Modules-_examples revised 2-26-12.docx Yes Yes Fillable Fileable
Form and Instruction 5 Occupational Job Exposure Modules - complete set Attach 5 - Occupational_Job_Modules_-_complete_set revised 2-26-12.docx Yes Yes Fillable Fileable
Form and Instruction 3A Screener and Core Questionnaire-Hong Kong (English) Attach 3A -Screen&CoreQx_HongKong_English.pdf Yes Yes Fillable Fileable
Form and Instruction 3B Screener and Core Questionnaire-Hong Kong (Chinese) Attach 3B -Screen&CoreQx_HongKong_Chinese.pdf Yes Yes Fillable Fileable
Form and Instruction 3C Screener and Core Questionnaire-Chengdu (English) Attach 3C -Screen&CoreQx_Chengdu_English.pdf Yes Yes Fillable Fileable
Form and Instruction 3D Screener and Core Questionnaire-Chengdu (Chinese) Attach 3D -Screen&CoreQx_Chengdu_Chinese.pdf Yes Yes Fillable Fileable
Form and Instruction 3E Screener and Core Questionnaire-Taiwan (English) Attach 3E -Screen&CoreQx_Taiwan_English.pdf Yes Yes Fillable Fileable
Form and Instruction 3F Screener and Core Questionnaire-Taiwan (Chinese) Attach 3F -Screen&CoreQx_Taiwan_Chinese.pdf Yes Yes Fillable Fileable
Form and Instruction 3G Screener and Core Questionnaire-Tianjin (English) Attach 3G -Screen&CoreQx_Tianjin_English.pdf Yes Yes Fillable Fileable
Form and Instruction 3H Screener and Core Questionnaire-Tianjin (Chinese) Attach 3H -Screen&CoreQx_Tianjin_Chinese.pdf Yes Yes Fillable Fileable
Form and Instruction 4 Occupational Job Exposure Modules - examples Attach 4 - Occupational_Job_Modules-_examples revised 2-26-12.docx Yes Yes Fillable Fileable
Form and Instruction 5 Occupational Job Exposure Modules - complete set Attach 5 - Occupational_Job_Modules_-_complete_set revised 2-26-12.docx Yes Yes Fillable Fileable

Federal Enterprise Architecture Business Reference Module


table that charts list of burden
  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 0 0 -5,300 0 0 5,300
Annual IC Time Burden (Hours) 0 0 -4,108 0 0 4,108
Annual IC Cost Burden (Dollars) 0 0 0 0 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.