Form 26 Attachment 26-1 AHS Phase IV Health Follow-up CAWI Proxy

26-1. AHS Phase IV Health Follow-Up CAWI Proxy Survey

OMB No.: 0925-0406
Expiration Date: 09/30/2016
Collection of this information is authorized by The Public Health Service Act (42 USC 285l). Rights of study
participants are protected by The Privacy Act of 1974. Participation is voluntary, and there are no penalties for
not participating or withdrawing from the study at any time. Refusal to participate will not affect your benefits in
any way. The information collected in this study will be kept private to the extent provided by law. Names and
other identifiers will not appear in any report of the study. Information provided will be combined for all study
participants and reported as summaries. You are being contacted by mail to complete this online health followup survey on behalf of the Agricultural Health Study cohort member because continued involvement can help
us learn more about how agricultural and environmental factors may affect the health of farmers and their
families.
Public reporting burden for this collection of information is estimated to average 10 - 15 minutes per response,
including the time for reviewing instructions, searching existing data sources, gathering and maintaining the
data needed, and completing and reviewing the collection of information. An agency may not conduct or
sponsor, and a person is not required to respond to, a collection of information unless it displays a
currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of
this collection of information, including suggestions for reducing this burden to: NIH, Project Clearance Branch,
6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0406). Do not return the
completed form to this address.

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