Information Collection

Phase IV Follow-up CAWI Survey, CATI Script or Paper/Pen

IC 220927 under ICR 201604-0925-001 · OMB 0925-0406.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 23 Phase IV Follow-up CAWI Survey, CATI Script or Paper/Pen	Form and Instruction
23 Attachment 25-1 AHS Phase IV Health Follow-up CAWI Parti Attachment 25-1. AHS Phase IV Health Follow-Up CAWI Participant Survey.pdf	Form and Instruction
24 Attachment 25-2 AHS Phase IV Health Follow-up CATI Proxy Attachment 26-2. AHS Phase IV Health Follow-Up CATI Proxy Survey Script.pdf	Form and Instruction
25 Attachment 25-3 AHS Phase IV Health Follow-up Paper & Pe Attachment 25-3 AHS Phase IV Health Follow-Up Paper & Pen Participant Survey.pdf	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?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	23	Attachment 25-1 AHS Phase IV Health Follow-up CAWI Participant Survey	Attachment 25-1. AHS Phase IV Health Follow-Up CAWI Participant Survey.pdf	Yes	No	Fillable Fileable
Form and Instruction	24	Attachment 25-2 AHS Phase IV Health Follow-up CATI Proxy Survey Script	Attachment 26-2. AHS Phase IV Health Follow-Up CATI Proxy Survey Script.pdf	Yes	No	Fillable Fileable
Form and Instruction	25	Attachment 25-3 AHS Phase IV Health Follow-up Paper & Pen Participant Survey	Attachment 25-3 AHS Phase IV Health Follow-Up Paper & Pen Participant Survey.pdf	Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: 09-25-0200 Clinical, Basic and Population-based Research Studies

FR Citation: 67 FR 60776

Number of Respondents: 13,855

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Farms, Businesses or other for-profits

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	13,855	13,855
Annual IC Time Burden (Hours)	5,773	5,773
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.