View Information Collection (IC)

View Information Collection (IC)

View Information Collection (IC)

IC Title:	[NCHS] CCQDER - Questions to Identify People with Intellectual and Developmental Disabilities at Point-of-Care Settings	Agency IC Tracking Number:	0920-25-0115

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	n/a	Screening Script	Attachment 4 -Screening Script.docx		No		Fillable Fileable
Form and Instruction	n/a	Questions to be Cognitively Tested	Attachment 1 - Questions.docx		Yes	Yes	Fillable Fileable
Form and Instruction	n/a	Respondent Data Collection Sheet	Attachment 6 - In Person & Virtual Respondent Data Collection Sheet.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: 225	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 90 %

	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	225	0	225	0	0	0
Annual IC Time Burden (Hours)	72	0	72	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
Purpose and Development of Questions	Attachment 2 - Purpose and Development of Questions.docx	07/07/2025
Advertisement 1	Attachment 3a - Advertisement 1.docx	07/07/2025
Advertisement 2	Attachment 3b - Advertisement 2.docx	07/07/2025
Advertisement 3	Attachment 3c - Advertisement 3.docx	07/07/2025
Advertisement 4	Attachment 3d - Advertisement 4.docx	07/07/2025
Advertisement 5	Attachment 3e - Advertisement 5.docx	07/07/2025
Informed Consent Forms	Attachment 5 - In Person & Virtual Informed Consent Forms.docx	07/07/2025
Thank You Letter	Attachment 7 - Thank You Letter.docx	07/07/2025
Data Retention Policy	Attachment 8 - Data Retention Policy.docx	07/07/2025
NCHS Non-Disclosure Affidavit	Attachment 9 - NCHS Non-Disclosure Affidavit.docx	07/07/2025
Research Determination	Attachment 10- IDD POC Cognitive Interview IRB Approval Letter.pdf	07/07/2025
SSA	SSA IDD Point of Care Cognitive Interviews.docx	07/07/2025

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