Jackson Heart Study Physicians

The Jackson Heart Study: Annual Follow-up with Third Party Respondents

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0491 can be found here:

Documents and Forms

Document Name Document Type
Form 1 Jackson Heart Study Physicians Form
1 Physician Questionnniare Attach 11-Physician Questionnaire (PHQ) Form.doc Form
2 Coroner-Medical Examiner Attach 12 -Coroner-Medical Examiner (COR) Form.doc Form

Information Collection (IC) Details

IC Title:	Jackson Heart Study Physicians	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	1	Physician Questionnniare	Attach 11-Physician Questionnaire (PHQ) Form.doc		Yes	Yes	Paper Only
Form	2	Coroner-Medical Examiner	Attach 12 -Coroner-Medical Examiner (COR) Form.doc		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 200	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	200	200
Annual IC Time Burden (Hours)	50	50
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.