Information Collection

Core Questionnaire & Occupational Job Module Consented Patient Controls

IC 218785 under ICR 201510-0925-005 · OMB 0925-0654.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 3 Core Questionnaire & Occupational Job Module Consented Patient Controls	Form and Instruction
1 Attachment 5 Occupational Job Modules Attach-5-Occupational_Job_Modules.pdf	Form and Instruction
2 Attachment 3A Updated Screener and Core Questionnaire Ho Attach-3A-Updated-Screener-and-Core-Questionnaire-Hong-Kong-English.doc	Form and Instruction
3 Attachment 3B Updated Screener and Core Questionnaire Ho Attach-3B-Updated-Screener-and-Core-Questionnaire-Hong-Kong-Chinese.doc	Form and Instruction
4 Attachment 3C Updated Screener and Core Questionnaire Ch Attach-3C-Updated-Screener-and-Core-Questionnaire-Chengdu-English.doc	Form and Instruction
5 Attachment 3D Updated Screener and Core Questionnaire Ch Attach-3D-Updated-Screener-and-Core-Questionnaire-Chengdu-Chinese.docx	Form and Instruction
6 Attachment 3E Updated Screener and Core Questionnaire Ti Attach-3E-Updated-Screener-and-Core-Questionnaire-Tianjin-English.doc	Form and Instruction
7 Attachment 3F Updated Screener and Core Questionnaire Ti Attach-3F-Updated-Screener-and-Core-Questionnaire-Tianjin-Chinese.doc	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Electronic Capability
Form and Instruction	3	Attachment 3B Updated Screener and Core Questionnaire Hong-Kong Chinese	Attach-3B-Updated-Screener-and-Core-Questionnaire-Hong-Kong-Chinese.doc	No	Fillable Fileable
Form and Instruction	4	Attachment 3C Updated Screener and Core Questionnaire Chengdu-English	Attach-3C-Updated-Screener-and-Core-Questionnaire-Chengdu-English.doc	No	Fillable Fileable
Form and Instruction	5	Attachment 3D Updated Screener and Core Questionnaire Chengdu-Chinese	Attach-3D-Updated-Screener-and-Core-Questionnaire-Chengdu-Chinese.docx	No	Fillable Fileable
Form and Instruction	6	Attachment 3E Updated Screener and Core Questionnaire Tianjin-English	Attach-3E-Updated-Screener-and-Core-Questionnaire-Tianjin-English.doc	No	Fillable Fileable
Form and Instruction	7	Attachment 3F Updated Screener and Core Questionnaire Tianjin-Chinese	Attach-3F-Updated-Screener-and-Core-Questionnaire-Tianjin-Chinese.doc	No	Fillable Fileable
Form and Instruction	1	Attachment 5 Occupational Job Modules	Attach-5-Occupational_Job_Modules.pdf	No	Fillable Fileable
Form and Instruction	2	Attachment 3A Updated Screener and Core Questionnaire Hong-Kong English	Attach-3A-Updated-Screener-and-Core-Questionnaire-Hong-Kong-English.doc	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 300

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	300	300
Annual IC Time Burden (Hours)	525	525
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.