View Information Collection (IC)

View Information Collection (IC)

IC Title:	[NCHS] COLLABORATING CENTER FOR QUESTIONNAIRE DESIGN AND EVALUATION RESEARCH	Agency IC Tracking Number:	0920-0222-23EQ

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	0920-0222-23EQ	Attachment 5a-5b Respondent Data Collection Sheet 4.28.23	Attachment 5a-5b Respondent Data Collection Sheet 4.28.23.docx		Yes	Yes	Fillable Fileable
Form and Instruction	0920- 0222-23EQ	Questions	Attachment 1- PCE Questions 4.28.23.docx		Yes	Yes	Fillable Fileable
Form and Instruction	0920-0222-23EQ	Screening Script	Attachment 3a-3c- Screening Script 4.28.23.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: 330	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	330	0	330	0	0	0
Annual IC Time Burden (Hours)	102	0	102	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
Attachment 2a-2c-Advertisement 4.5.23	Attachment 2a-2c-Advertisement 4.5.23.docx	05/05/2023
Attachment 4a-4f- Informed Consent 4.28.23	Attachment 4a-4f- Informed Consent 4.28.23.docx	05/05/2023
Attachment 6- PCE Thank You Letter	Attachment 6- PCE Thank You Letter.docx	05/05/2023
Attachment 7-Data Retention Policy	Attachment 7-Data Retention Policy.docx	05/05/2023
Attachment 8 -Distress guide	Attachment 8 -Distress guide.docx	05/05/2023
Attachment 9- NCHS Non-Disclosure Affidavit 4.28.23	Attachment 9- NCHS Non-Disclosure Affidavit 4.28.23.docx	05/05/2023
SSB-Childhood Experiences 4.28.23	SSB-Childhood Experiences 4.28.23.docx	05/05/2023
Sup. Stmt. Part A: Childhood Experiences	SSA-Childhood Experiences 5.31.23 Clean.docx	05/31/2023

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.