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  
To view an IC, click on IC Title