Information Collection

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

IC 220929 under ICR 201604-0925-001 · OMB 0925-0406.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 26 Phase IV Follow-up CAWI Survey, CATI Script or Paper/Pen	Form and Instruction
26 Attachment 26-1 AHS Phase IV Health Follow-up CAWI Proxy Attachment 26-1. AHS Phase IV Health Follow-Up CAWI Proxy Survey.pdf	Form and Instruction
27 Attachment 26-2 AHS Phase IV Health Follow-up CATI Proxy 26-2. AHS Phase IV Health Follow-Up CATI Proxy Survey Script.pdf	Form and Instruction
28 Attachment 26-3 AHS Phase IV Health Follow-up Paper & Pe Attachment 26-3 AHS Phase IV Health Follow-Up Paper & Pen Proxy 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	26	Attachment 26-1 AHS Phase IV Health Follow-up CAWI Proxy Survey	Attachment 26-1. AHS Phase IV Health Follow-Up CAWI Proxy Survey.pdf	Yes	No	Fillable Fileable
Form and Instruction	27	Attachment 26-2 AHS Phase IV Health Follow-up CATI Proxy Survey Script	26-2. AHS Phase IV Health Follow-Up CATI Proxy Survey Script.pdf	Yes	No	Fillable Fileable
Form and Instruction	28	Attachment 26-3 AHS Phase IV Health Follow-up Paper & Pen Proxy Survey	Attachment 26-3 AHS Phase IV Health Follow-Up Paper & Pen Proxy 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: 635

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	635	635
Annual IC Time Burden (Hours)	159	159
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.