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Agenda
Reg Review
ICR
View Information Collection (IC)
View Information Collection (IC)
IC Title:
Questionnaire Design and Evaluation Research on Injury for the National Health Interview Survey (NHIS)
Agency IC Tracking Number:
0920-0222-18DO
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 and Instruction
NA
Telephone Screener
Attach 3 - Telephone Screener.docx
NA
No
Paper Only
Form and Instruction
NA
Questionnaire - Injury Questions to Evaluate
Attach 1 - Questionnaire.docx
NA
No
Paper Only
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Public Health Monitoring
Privacy Act System of Records
Title:
09-20-0164 - Health and Demographic Surveys Conducted 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:
0 %
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
Study Participation Ad/Flyer
Attach 2a&b Ads&Flyers.docx
10/27/2017
Informed Consent - Interview
Attach 4 - Informed Consent.docx
10/27/2017
Special Consent for Expanded Use of Video and Audio Recordings
Attach 7 - Spec Consent.docx
10/27/2017
Respondent Data Collection Sheet
Attach 5 - Resp Data Collect Sheet.docx
10/27/2017
Thank You Letter
Attach 6 - Thank You Ltr.docx
10/27/2017
10-Day Letter
10-day letter NHIS Injury 102617.docx
10/27/2017
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.