NCHS Questionnaire Design Research Laboratory

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form Attachment 1 Respiratory Health Internet Version	Form and Instruction	New	Available
NHIS 2013 questions	Form	New	Available
575 ACASI Field Test	Form and Instruction	New	Available
Blood Donor History Questionnaire	Form and Instruction	New	Available
Survey on Respiratory Health	Form and Instruction	New	Repair queued
ACASI field interviews	Form and Instruction	New	Available
2012 Asthma Supplement	Form	New	Available
Spanish version - ACASI testing of sexual identity questions	Form	New	Available
Att 2 - Cognitive testing interview guide	Form	New	Available
NHBS - Spanish screener	Form	New	Repair queued
Child Component of CAMS	Form	New	Available
Physican Workflow EHR some Adoption Survey	Form	New	Available
Physican Workflow EHR no Adoption Survey	Form	New	Repair queued
NHBS - Spanish version for MSM	Form	New	Repair queued
NHBS screeners	Form	New	Available
NHBS questions for cognitive testing	Form	New	Available
National Survey of Children's Health	Form	New	Available
Patient Record Evaluation	Form	New	Repair queued
CAM - interview guide	Form	New	Available
Measuring Trust - questions	Form	New	Available
Form No number Testing NHIS and NHANES Questions	Form	New	Available
NHIS Voice, Swallowing, Speech and Language	Form	New	Available
QDRL - Disability Study	Form	New	Available
QDRL-OMB Supporting Statement B- final 112709.doc	Supporting Statement B	Uploaded 2010-01-22	Available
QDRL-OMB Attachment O.doc	Supplementary Document	Uploaded 2010-01-22	Available
QDRL-OMB Attachment N.doc	Supplementary Document	Uploaded 2010-01-22	Available
QDRL-OMB Attachment M.doc	Supplementary Document	Uploaded 2010-01-22	Repair queued
QDRL-OMB Attachment L.doc	Supplementary Document	Uploaded 2010-01-22	Repair queued
QDRL-OMB Attachment K.doc	Supplementary Document	Uploaded 2010-01-22	Repair queued
QDRL-OMB Attachment J.doc	Supplementary Document	Uploaded 2010-01-22	Available
QDRL-OMB Attachment I.doc	Supplementary Document	Uploaded 2010-01-22	Available
QDRL-OMB Attachment H.doc	Supplementary Document	Uploaded 2010-01-22	Available
QDRL-OMB Attachment G.doc	Supplementary Document	Uploaded 2010-01-22	Available
QDRL-OMB Attachment F.doc	Supplementary Document	Uploaded 2010-01-22	Repair queued
QDRL-OMB Attachment E.doc	Supplementary Document	Uploaded 2010-01-22	Repair queued
QDRL-OMB Attachment D.doc	Supplementary Document	Uploaded 2010-01-22	Available
QDRL-OMB Attachment C.doc	Supplementary Document	Uploaded 2010-01-22	Repair queued
QDRL-OMB Attachment B.doc	Supplementary Document	Uploaded 2010-01-22	Available
QDRL-OMB Attachment A.doc	Supplementary Document	Uploaded 2010-01-22	Available
QDRL-2010-12 Supporting Statement A - final final 021710.doc	Supporting Statement A	Uploaded 2010-02-17	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
201870	Evaluation of the Internet Version of the Respiratory Health of Healthcare Workers Questionnaire	Form and Instruction	New	Respiratory Health Internet Version
201536	QDRL - 2013 NHIS	Form	New	NHIS 2013 questions
200804	NHIS 575 ACASI Field Interviews	Form and Instruction	New	575 ACASI Field Test
200032	Respiratory Health of Healthcare Workers and Blood Donor History Questionnaires	Form and Instruction	New	Blood Donor History Questionnaire
200032	Respiratory Health of Healthcare Workers and Blood Donor History Questionnaires	Form and Instruction	New	Survey on Respiratory Health
199758	ACASI field interviews for NHIS	Form and Instruction	New	ACASI field interviews
199221	Testing Long Term Care Questions	Other-Interview	New
198749	Asthma Management Supplement	Form	New	2012 Asthma Supplement
197794	QDRL - Spanish version of ACASI testing for sexual identity questions	Form	New	Spanish version - ACASI testing of sexual identity questions
197466	QDRL - ACASI testing for sexual identity question on NHIS	Form	New	Att 2 - Cognitive testing interview guide
196057	QDRL testing on NAMCS physician follow-up, NHIS Complementary and Alternative Medicine, and Spanish version of HIV behavioral surveillance	Form	New	NHBS - Spanish screener
196057	QDRL testing on NAMCS physician follow-up, NHIS Complementary and Alternative Medicine, and Spanish version of HIV behavioral surveillance	Form	New	Child Component of CAMS
196057	QDRL testing on NAMCS physician follow-up, NHIS Complementary and Alternative Medicine, and Spanish version of HIV behavioral surveillance	Form	New	Physican Workflow EHR some Adoption Survey
196057	QDRL testing on NAMCS physician follow-up, NHIS Complementary and Alternative Medicine, and Spanish version of HIV behavioral surveillance	Form	New	Physican Workflow EHR no Adoption Survey
196057	QDRL testing on NAMCS physician follow-up, NHIS Complementary and Alternative Medicine, and Spanish version of HIV behavioral surveillance	Form	New	NHBS - Spanish version for MSM
195459	QDRL - questions for National HIV Behavioral Surveillance system and on gender	Form	New	NHBS screeners
195459	QDRL - questions for National HIV Behavioral Surveillance system and on gender	Form	New	NHBS questions for cognitive testing
195152	QDRL - SLAITS National Survey of Children's Health	Form	New	National Survey of Children's Health
194864	NAMCS and NHAMCS Patient Record Evaluation	Form	New	Patient Record Evaluation
193785	Measuring Trust in Official Statistics and Complementary and Alternative Medicine for NHIS	Form	New	CAM - interview guide
193785	Measuring Trust in Official Statistics and Complementary and Alternative Medicine for NHIS	Form	New	Measuring Trust - questions
193241	Conducting Testing on NHIS and NHANES Questions	Form	New	Testing NHIS and NHANES Questions
192888	QDRL - NCHS Website Usability Testing	Instruction	New
192790	NHIS Voice, Swallowing, Speech, Language and NHANES Creatine and Lifestyle Questions	Form	New	NHIS Voice, Swallowing, Speech and Language
192246	Questionnaire Design Research Laboratory - Disability Study	Form	New	QDRL - Disability Study

ICR Details

OMB Control No: 0920-0222	ICR Reference No: 201002-0920-006
Status: Historical Active	Previous ICR Reference No: 200902-0920-005
Agency/Subagency: HHS/CDC	Agency Tracking No:
Title: NCHS Questionnaire Design Research Laboratory
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 03/01/2010
Retrieve Notice of Action (NOA)	Date Received in OIRA: 02/17/2010
Terms of Clearance: CDC will continue to submit individual collections under this generic clearance to OMB. OMB will provide feedback on the individual collections within ten working days, whenever possible, as is currently the case. Standard remuneration of respondents is $40.00. Higher remunerations may be requested with justification for difficult recruitments, focus groups, etc.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2013	36 Months From Approved	02/28/2010
Responses	850	0	850
Time Burden (Hours)	1,800	0	600
Cost Burden (Dollars)	0	0	0

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Abstract: This submission describes proposed research activities of the National Center for Health Statistics (NCHS) Questionnaire Design Research Laboratory. Survey specific research activities include questionnaire testing and development for NCHS, CDC, other federal agencies, or other academic or professional institutions. The purpose and use of collecting this information fall into five categories: 1) Development and testing of specific survey questionnaires; 2) Research on the cognitive and interpretive aspects of survey methodology; 3) Research on human-computer interfaces/usability; 4) Pilot household interviewing; and 5) Studies of the optimal design and presentation of statistical graphical and textual material. Methods for data collection include interviewer administered, self-administered, telephone, Computer Assisted Personal Interviewing (CAPI) and Computer Assisted Self-Interviewing (CASI), and web-based questionnaires including: cognitive interviewing, focus groups, usability testing, and pilot household interviews.

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Authorizing Statute(s): US Code: 42 USC 242k Name of Law: Public Health Service Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	74 FR 48077	09/21/2009
30-day Notice:	Federal Register Citation:	Citation Date:
	75 FR 3737	01/22/2010
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 18

table that charts list of burden

IC Title	Form No.	Form Name
ACASI field interviews for NHIS	none	ACASI field interviews
Asthma Management Supplement	none	2012 Asthma Supplement
Conducting Testing on NHIS and NHANES Questions	No number	Testing NHIS and NHANES Questions
Evaluation of the Internet Version of the Respiratory Health of Healthcare Workers Questionnaire	Attachment 1	Respiratory Health Internet Version
Measuring Trust in Official Statistics and Complementary and Alternative Medicine for NHIS	none, none	Measuring Trust - questions ,   CAM - interview guide
NAMCS and NHAMCS Patient Record Evaluation	none	Patient Record Evaluation
NHIS 575 ACASI Field Interviews	none	575 ACASI Field Test
NHIS Voice, Swallowing, Speech, Language and NHANES Creatine and Lifestyle Questions	none	NHIS Voice, Swallowing, Speech and Language
QDRL - 2013 NHIS	none	NHIS 2013 questions
QDRL - ACASI testing for sexual identity question on NHIS	none	Att 2 - Cognitive testing interview guide
QDRL - NCHS Website Usability Testing
QDRL - SLAITS National Survey of Children's Health	none	National Survey of Children's Health
QDRL - Spanish version of ACASI testing for sexual identity questions	none	Spanish version - ACASI testing of sexual identity questions
QDRL - questions for National HIV Behavioral Surveillance system and on gender	none, none	NHBS questions for cognitive testing ,   NHBS screeners
QDRL testing on NAMCS physician follow-up, NHIS Complementary and Alternative Medicine, and Spanish version of HIV behavioral surveillance	none, none, none, none, none	Physican Workflow EHR no Adoption Survey ,   Physican Workflow EHR some Adoption Survey ,   Child Component of CAMS ,   NHBS - Spanish version for MSM ,   NHBS - Spanish screener
Questionnaire Design Research Laboratory - Disability Study	none	QDRL - Disability Study
Respiratory Health of Healthcare Workers and Blood Donor History Questionnaires	none, none	Survey on Respiratory Health ,   Blood Donor History Questionnaire
Testing Long Term Care Questions

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ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	850	850	0	0	0	0
Annual Time Burden (Hours)	1,800	600	0	0	1,200	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $1,002,450

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 02/17/2010

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