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Agenda
Reg Review
ICR
View Information Collection (IC)
View Information Collection (IC)
IC Title:
Cognitive testing of Confidentiality Pledge, Round 2
Agency IC Tracking Number:
16BFN
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
Other-WORD
Attach 3 Telehphone Screener.docx
Yes
Yes
Fillable Printable
Other-WORD
Attach 5 Resp Data Collect Sheet.docx
Yes
Yes
Fillable Printable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Public Health Monitoring
Privacy Act System of Records
Title:
09-06-0164 Health and Demographic Surveys Condcuted in Probability Samples of the U.S. Population
FR Citation:
49 FR 37693
Number of Respondents:
68
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
100 %
Approved
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
68
0
68
0
0
0
Annual IC Time Burden (Hours)
24
0
24
0
0
0
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
Att 1_ Confidentiality Pledge
Attach 1 092616.docx
09/28/2016
Att 2_Ads & Flyers
Attach 2 Advertisement&flyer.docx
09/28/2016
Att 4_Informed Consent
Attach 4 Informed Consent.docx
09/28/2016
Att 6_Thank you Letter
Attach 6 Thank You Letter.docx
09/28/2016
Att 7_Spec Consent
Attach 7 Spec Consent.docx
09/28/2016
Request for Approval
Confid Pledge 10-day letter 0928 2016.docx
09/28/2016
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.