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Agenda
Reg Review
ICR
View Information Collection (IC)
View Information Collection (IC)
IC Title:
Cognitive Interviewing Study of Opioid-Related Questions (Spanish Version)
Agency IC Tracking Number:
0920-18AHJ
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
n/a
Sample screening script for respondent contact Cognitive interviewing study of opioid use and pain questions
Attach 3 Spanish Telephone Screener 051518.docx
No
Paper Only
Form and Instruction
n/a
Spanish Questions to be cognitively tested
Attach 1 Spanish Questionnaire.doc
No
Paper Only
Form and Instruction
n/a
Spanish Respondent Data Collection Sheet
Attach 5 Spanish Resp Data Collect.docx
No
Paper Only
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Public Health Monitoring
Privacy Act System of Records
Title:
Health and Demographic Surveys Conducted in Probability Samples of the U. S. Population 09-20-0164
FR Citation:
49 FR 37693
Number of Respondents:
96
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
96
0
96
0
0
0
Annual IC Time Burden (Hours)
68
0
68
0
0
0
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
Project Description (10-day Letter)
Spanish Opioid 10-day 051518.docx
05/17/2018
Recruitment Ad for Spanish Speaking Participants
Attach 2 Spanish Advertisement.docx
05/17/2018
Informed Consent Form for Spansih Study
Attach 4 Spanish Informed Consent.docx
05/17/2018
Thank You Letter
Attach 6 Spanish Thank You Letter.docx
05/17/2018
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.