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Agenda
Reg Review
ICR
View Information Collection (IC)
View Information Collection (IC)
IC Title:
CCQDER - Cognitive Testing Questions for the 2022 NAMCS
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
0920-0222
Telephone Screening Script – Respondent recruited from newspaper advertisement/flyer
NAMCS OMB Attachment 4a 4b_Telephone Screening Script_revised Assurance_01112022.docx
No
Paper Only
Form
0920-0222
Adult Informed Consent Form for
NAMCS OMB Attachment 5a 5b_Informed Consent_revised Assurance.docx
No
Fillable Fileable
Form
0920-0222
Respondent Data Collection Sheet
NAMCS OMB Attachment 6a 6b_Data Collection Sheet_revised Assurance.docx
Yes
Yes
Fillable Fileable
Form
0920-0222
Respondent Debriefing Interview (virtual interviews)
NAMCS OMB Attachment 8_Follow Up Interview_revised Assurance.docx
Yes
No
Fillable Fileable
Form and Instruction
1a
Questionnaire
NAMCS OMB Attachment 1a_Questionnaire_revised Assurance.docx
Yes
Yes
Fillable Fileable
Form and Instruction
1b
Questionnaire
NAMCS OMB Attachment 1b_Questionnaire_revised Assurance.docx
Yes
Yes
Fillable Fileable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Public Health Monitoring
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
40
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
75 %
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
40
0
40
0
0
0
Annual IC Time Burden (Hours)
29
0
29
0
0
0
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
NAMCS 10-day Letter
NAMCS 10-day-letter 01112022_SK.docx
01/27/2022
Provenance of Questions to be Cognitively Tested
NAMCS OMB Attachment 2_Question Provenance.docx
01/27/2022
Participants Wanted for Research Study Advertisement
NAMCS OMB Attachment 3a 3b_Advertisements.docx
01/27/2022
Thank You Letter
NAMCS OMB Attachment 7_Thank You Letter.docx
01/27/2022
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.