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Agenda
Reg Review
ICR
View Information Collection (IC)
View Information Collection (IC)
IC Title:
Cognitive Test for NHIS Questions and Opiods
Agency IC Tracking Number:
0920-0222-19AUJ
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
0920-0222
Questions to be Cognitively Tested
GenIC 0920-0222 Cognitive Test NHIS & CCQDER Attach 1 Questions.docx
No
Fillable Fileable
Form and Instruction
0920-0222
Screeners
GenIC 0920-0222 Cognitive Test NHIS & CCQDER Attach 3ab Screeners.docx
No
Fillable Fileable
Form and Instruction
0920-0222
Respondent Data Collection Sheet
GenIC 0920-0222 Cognitive Test NHIS & CCQDER Attach 5 Resp Data.docx
No
Fillable Fileable
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:
160
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
160
0
160
0
0
0
Annual IC Time Burden (Hours)
49
0
49
0
0
0
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
10 Day Letter (GenIC info)
GenIC 0920-0222 NHIS and CCQDER 10-day letter 05 03 2019 ICRO.doc
05/20/2019
Ads
GenIC 0920-0222 Cognitive Test NHIS & CCQDER Attach 2ab Ads.docx
05/20/2019
Consent
GenIC 0920-0222 Cognitive Test NHIS & CCQDER Attach 4 Consent.docx
05/20/2019
Thank You Letter
GenIC 0920-0222 Cognitive Test NHIS & CCQDER Attach 6 Letter.docx
05/20/2019
Special Consent
GenIC 0920-0222 Cognitive Test NHSI & CCQDER Attach 7 Special Consent.docx
05/20/2019
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.