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Agenda
Reg Review
ICR
View Information Collection (IC)
View Information Collection (IC)
IC Title:
NSCH Screener Cognitive Interviews
Agency IC Tracking Number:
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
1
Screener Card
Screener Card Content - 2 options_OMB.docx
No
Fillable Fileable
Form and Instruction
2
Experimental Treatment B - NonPerforated Mockup 1
NSCH11wa - Experimental Treatment B_Non-perforated Mockup 1_OMB.docx
No
Fillable Fileable
Form and Instruction
3
Experimental Treatment B - NonPerforated Mockup 2
NSCH11wa - Experimental Treatment B_Non-perforated Mockup 2_OMB.docx
No
Fillable Fileable
Form and Instruction
4
Experimental Treatment B - Perforated Mockup 1
NSCH11wa - Experimental Treatment B_Perforated Mockup 1_OMB.docx
No
Fillable Fileable
Form and Instruction
5
Experimental Treatment B - Perforated Mockup 2
NSCH11wa - Experimental Treatment B_Perforated Mockup 2_OMB.docx
No
Fillable Fileable
Form and Instruction
6
Experimental Treatment C
NSCH11wa - Experimental Treatment C_OMB.docx
No
Fillable Fileable
Form and Instruction
7
Standard Treatments A and D
NSCH11wa - Standard Version (Treatments A and D)_OMB.docx
No
Fillable Fileable
Form and Instruction
8
NonPerforated Mockup 1
NSCH12wa - Non-perforated Mockup 1_OMB.docx
No
Fillable Fileable
Form and Instruction
9
NonPerforated Mockup 2
NSCH12wa - Non-perforated Mockup 2_OMB.docx
No
Fillable Fileable
Form and Instruction
10
Perforated Mockup 1
NSCH12wa - Perforated Mockup 1_OMB.docx
No
Fillable Fileable
Form and Instruction
11
Perforated Mockup 2
NSCH12wa - Perforated Mockup 2_OMB.docx
No
Fillable Fileable
Federal Enterprise Architecture Business Reference Module
Line of Business:
General Government
Subfunction:
Central Records & Statistical Mgt
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
30
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
30
0
30
0
0
0
Annual IC Time Burden (Hours)
36
0
36
0
0
0
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
OMB Memo
OMB letter - NSCH Screener cognitive interviewing_OMB (2).docx
10/11/2018
Protocol
NSCH Screener Cognitive Interviewing Protocol _OMB.docx
10/11/2018
Screener
Participant Screener_NSCH Screener Card_OMB (2).docx
10/11/2018
Consent Form
NSCH Screener Consent Form_OMB.doc
10/11/2018
Voucher
NSCH Screener Voucher_OMB.docx
10/11/2018
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.
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The .gov means it's official.
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