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Agenda
Reg Review
ICR
View Information Collection (IC)
View Information Collection (IC)
IC Title:
2021 AHS Cognitive Testing
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
Protocol and Questionnaire for Cognitive Interviews
Enclosure 1 - AHS 2021 Protocol_In Person & Remote Interviews.docx
No
Fillable Fileable
Form and Instruction
2
Qualtrics Survey Questionnaire
Enclosure 5-Qualtrics Survey Questionnaire_FINAL_07292020.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:
165
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
91 %
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
165
0
165
0
0
0
Annual IC Time Burden (Hours)
56
0
56
0
0
0
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
OMB Memo
OMB Memo_AHS 2021 Cognitive Testing_FINAL_07292020.docx
07/30/2020
Screener
Enclosure 2 - Recruitment Screener w PA Language_clean.docx
07/06/2020
BOC and Craigslist Ads
Enclosure 3a - AHS Combo Ad_BOC Email and Craigslist.docx
06/17/2020
Ad Flyer
Enclosure 3b - AHS 2021 recruiting flyer.pub
06/17/2020
Consent Form
Enclosure 4-Consent Form w PA Language_clean.docx
07/06/2020
Previously Approved Universal Screener w/ privacy language
Screener Part A-clean.docx
07/06/2020
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.