View Information Collection (IC)

View Information Collection (IC)

View Information Collection (IC)

IC Title:	NHANES Special Studies	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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
Other-Other			Att_10_Spec_Studies 15-16 110915.docx		No		Paper Only
Form and Instruction	none	ABPM Screener	ATT1b_ ABPM Screener 071416.docx		Yes	Yes	Fillable Fileable
Form	none	Pre-ABPM Form	ATT1d_ Pre ABPM Form 071416.docx		Yes	Yes	Fillable Fileable
Form	none	ABPM Diary Form	ATT1f_ ABPM Study Diary 062816.docx		Yes	Yes	Fillable Fileable
Form	none	ABPM Post- ABPM Form	ATT1g_ Post ABPM Form 062816.docx		Yes	Yes	Fillable Fileable
Form	none	Multi-mode Screener	ATT2b_ Multi-Mode Screener 060316.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: 09-20-0164 Health and Demographic Surveys Conducted in Probability Samples of the US Population	FR Citation: 49 FR 37693

Number of Respondents: 3,500	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	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	3,500	0	0	0	0	3,500
Annual IC Time Burden (Hours)	10,500	0	0	0	0	10,500
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
ABPM Description	ATT1a_ ABPM 071416.docx	07/20/2016
ABPM Consent	ATT1c_ ABPM Consent 071416.docx	07/20/2016
ABPM Info Sheet	ATT1e_ ABPM Info Sheet 071416.docx	07/20/2016
ABPM Report of Findings	ATT1h_ ABPM ROF 071416.docx	07/20/2016
Multi-mode screening description	ATT2a_ Multi-Mode Screener 070716.docx	07/20/2016
Advance Letter	ATT2c_ MM Advance Letter 070716.docx	07/20/2016
Postcard Reminder	Att2d_ MM WebScreener Postcard 070716.docx	07/20/2016
Second Letter	Att2e MM Second Letter 070716.docx	07/20/2016
Screener Screenshots	Att2f_MM Screenshots 070716.docx	07/20/2016
Consent Changes	ATT3a Consents Changes 060316.docx	07/20/2016
Revised Consents	ATT3b Revised Consents 060316.docx	07/20/2016

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