Information Collection

Cognitive Interviews for Prescription Drug Module Redesign

IC 195383 under ICR 200711-0930-002 · OMB 0930-0290.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0930-0290 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Attachment F-Instr Instrument and Protocol Cognitive Interviews for Prescription Drug Module Redesign	Form and Instruction
Attachment F-Instr Instrument and Protocol Attachment F_RxDrugs_Cognitive Protocol_2010_Nov8.doc	Form and Instruction
Attachment B Cognitive Recruitment Screener_2010_Oct.docm Attachment B-Recruitment Screener	IC Document
Attachment C Cover Letter_2010_4_23.docm Attachment C-Cover Letter	IC Document
PD OMB Memo.doc Transmittal Memo	IC Document
Attachment G Cognitive Receipt for Participation_2010_4_23.docm Attachment G-Receipt for Participation	IC Document
BTDB_PD_OMB_SS_final_12_16.doc Supporting Statement	IC Document
Attachment_A_Cognitive_Recruitment_Flyers_12_16.doc Cognitive Recruitment Flyer	IC Document
Attachment_D_-_Parental_Informed_Consent_Form_12_16.doc Parental Informed Consent Form	IC Document
Attachment_E_Participant_Informed_Consent_12_16.doc Participant Informed Consent	IC Document

IC Title:

Cognitive Interviews for Prescription Drug Module Redesign

Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	Attachment F-Instrument and Protocol				Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 240

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	240	240
Annual IC Time Burden (Hours)	92	92
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachment B-Recruitment Screener		11/17/2010
Attachment C-Cover Letter		11/17/2010
Transmittal Memo		11/17/2010
Attachment G-Receipt for Participation		11/17/2010
Supporting Statement		12/17/2010
Cognitive Recruitment Flyer		12/17/2010
Parental Informed Consent Form		12/17/2010
Participant Informed Consent		12/17/2010

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

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