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Agenda
Reg Review
ICR
Information Collection List
IC Title
Status
Responses
Hours
Dollars
Document Type
Form No.
Form Name
2016 CDC Healthcare Systems Scorecard (HSSC) Assessment Tool for Primary Care Practices
New
92
26
0
Form
none
Screener
Form
none
Interview Questionnaire
Form
none
Demographic Sheet
2017 NHANES Health Behaviors Cognitive Interviewing Study
New
156
68
0
Form and Instruction
0920-0222 (16AG)
Appendix 3 - NHANES Screener 090215
Form and Instruction
0920-0222 (16AG)
Appendix 1 - NHANES Questions for Cognitive Testing
Form and Instruction
0920-0222 (16AG)
Appendix 2a&b - NHANES Adv Flyer
Form and Instruction
0920-0222 (16AG)
Appendix 4 - NHANES Informed Consent
Form and Instruction
0920-0222 (16AG)
Appendix 5 - Special Consent
2017 NHANES Health Behaviors Cognitive Interviewing Study
New
126
38
0
Other-WORD
Other-WORD
2017 NHANES Health Behaviors Cognitive Interviewing Study/Spanish
New
68
24
0
Form and Instruction
0920-0222
Appendix 1 Questionnaire Spanish NHANES 100215
Form and Instruction
0920-0222
Appendix 2a&b Ad&Flyer Spanish NHANES
Form and Instruction
0920-0222
Appendix 3 Telephone Screener Spanish NHANES 100215
Form and Instruction
0920-0222
Appendix 5 Resp Data Collection Sheet Spanish NHANES
Instruction
Instruction
CQDER - Opioid Plus Card Sort
New
560
230
0
Form and Instruction
0920-0222
Opioid Questionnaire - Card Sort
Form and Instruction
0920-0222
Telephone Screener
Center for Questionnaire Design and Evaluation Research (CQDER) CMS 10-day Letter
New
100
50
0
Instruction
Form and Instruction
0920-16AEE
CQDER CMS Att 3ab Telephone Screener
Form and Instruction
0920-16AEE
CQDER CMS Att 5ab Resp Data Collect
Form and Instruction
0920-16AEE
CQDER CMS Att 1ab Qnne wshowcards
Cognitive Interviewing Study of Opioid-Related Questions
New
360
230
0
Form and Instruction
n/a
Questionnaire for Cognitive Testing of Opioid Questions
Form and Instruction
n/a
Telephone Screener for Individuals Recruited through the Newspaper Ad
Form
n/a
Respondent Data Collection Sheet (completed during the cognitive interview)
Cognitive Interviewing Study of Opioid-Related Questions (Spanish Version)
New
96
68
0
Form and Instruction
n/a
Sample screening script for respondent contact Cognitive interviewing study of opioid use and pain questions
Form and Instruction
n/a
Spanish Questions to be cognitively tested
Form and Instruction
n/a
Spanish Respondent Data Collection Sheet
Cognitive Testing of ASPE Criminal Justice System Questions
New
117
45
0
Other-WORD
Other-WORD
Cognitive Testing of Impaired Driving Questions for CDC National Center for Injury Prevention and Control (NPIPC)
New
112
46
0
Form and Instruction
0920-0222
Imp Driving - Attach 3 Screener rev-kw
Form and Instruction
0920-0222
Imp Driving - Attach 5 Resp Data Collection Sheet
Cognitive Testing of Middle Eastern North African (MENA) Questions
New
316
118
0
Form
None
Questions to be cognitively tested
Form
None
Telephone screening script
Form
None
Respondent data collection sheet
Cognitive Testing of NHIS health care utilization smoking, and selected child questions
New
112
46
0
Form and Instruction
092017AUC
Attach 3 Telephone Screener vcb 051017kw no confid pld update
Form and Instruction
0920-17AUC
Attach 3 Telephone Screener vcb 051017kw no confid pld update
Cognitive Testing of National Survey of Hospital-Based Victim Services (NSHVS)
New
92
26
0
Other-Telephone script
Form
none
National Survey of Hospital-based Victim Services
Form
none
Respondent Data Sheet
Cognitive Testing of Questions on Teen Alcohol and Marijuana Use
New
78
34
0
Form and Instruction
NA
Telephone Screening Script- Cognitive Testing of Questions on Teen Alcohol and Marijuana Use
Form and Instruction
NA
Teen Alcohol and Marijuana Use Questions to be Cognitively Tested
Cognitive testing of Confidentiality Pledge, Round 2
New
68
24
0
Other-WORD
Other-WORD
Cognitve Testing of Food for Babies and Mothers' Health Question on the NHANES B24 Month Questionnaire
New
185
75
0
Other-WORD
Other-WORD
Other-WoRD
Other-WORD
Collaborating Center for Questionnaire Design and Evaluation Research (CCQDER)
New
112
46
0
Form and Instruction
0920-0222
National Study of Long-Term Care Provider 2016 Adult Day Services Center Questionnaire
Form and Instruction
0920-0222
National Study of Long-Term Care Providers 2016 Residential Care Community Questionnaire
Form and Instruction
0920-0222
Adult Day Care Services Center (ADSC) Telephone Screening Script
Form and Instruction
0920-0222
Residential Care Community (RCC) Telephone Screening Script
Congitive Testing of Confidentiality Pledges
New
68
24
0
Other-Testing Materials
Other-Screening script
Form
none
Respondent data collection sheet
Evaluation of Traumatic Brain Injury Questions for CDC's National Center for Injury Prevention and Control (NCIPC)
New
112
46
0
Form and Instruction
NA
Telephone Screening Script for Adult/Self-Responder or Adult Proxy for Child 5-17
Form and Instruction
NA
Questions to be Cognitively Tested
GenIC UNICEF/Washington Group School Environment Evaluation Study 2016
New
26
18
0
Other-WORD
Other-WORD
Labor Force Module of Persons with Disabilities
New
68
24
0
Other-Telephone Screener
Other-Telephone Questionnaire
Labor Force Module of Persons with Disabilities Round 2
New
68
24
0
Other-WORD
Other-WORD
Other-WORD
Form and Instruction
1
Questionnaire
NHANES Contact and Message Testing
New
164
105
0
Other-ord
Other-SCREENER
PRAMS - English
New
68
34
0
Form
none
PRAMS Phase 8 Supplemental Questions
Form
none
PRAMS screener
PRAMS Phase 8 - Spanish
New
68
34
0
Form
none
PRAMS Phase 8 - Spanish
Form and Instruction
none
Screener
Form
none
Respondent Data Sheet
Questionnaire Design and Evaluation Research on Injury for the National Health Interview Survey (NHIS)
New
68
24
0
Form and Instruction
NA
Telephone Screener
Form and Instruction
NA
Questionnaire - Injury Questions to Evaluate
RANDS
New
4132
1399
0
Form
none
Telephone Screener
Form
none
Interview Questionnaire
Form
none
Web Intro Screen
Form
none
Respondent Demographic Data
Research and Development Survey (RANDS) Cognitive Interviewing Sub-Study
New
200
90
0
Other-WORD
Other-WORD
Spanish Cognitive Study to Examine Traumatic Brain Injury Questions
New
58
14
0
Form
none
Spanish Questions - TBI
Form and Instruction
none
Spanish Telephone Screener
Form
none
Spanish Data Collection Sheet
Testing of questions on cognitive functioning and other questions for the National Health Interview Survey (NHIS)
New
112
46
0
Form and Instruction
NA
NHIS Cognitive Functioning and other questions to be cognitively tested
Form and Instruction
NA
Telephone Screening Script
Trust, Acceptance and Confidence in Vaccines and Vaccination Schedules
New
258
124
0
Form and Instruction
NA
Focus Group Screener
Form and Instruction
NA
Cognitive Interview Screener
Form and Instruction
NA
Focus Group Moderator Guide
Form and Instruction
NA
Cognitive Interview Moderator Guide
Total Burden Actually Used for Information Collections Under Currently Approved ICR:
8220
3200
0
Total Burden Currently Requested for Information Collections Under Currently Approved ICR:
0
0
0
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