National Health Interview Survey

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 7 Adult Cancer--Line 7	Form and Instruction	Modified	Repair queued
Form 6 Family Disability--Line 6	Form and Instruction	Modified	Repair queued
Form 5 Child and Adult Immunization--Line 5	Form and Instruction	Modified	Available
Form 4 Child Core--line 4	Form and Instruction	Modified	Available
Form 3 Adult Core--line 3	Form and Instruction	Modified	Available
Form 2 Family Core - line 2	Form and Instruction	Modified	Available
Form 1 Screener Questionnaire--Line 1	Form and Instruction	Modified	Available
Form 15 Reinterview Survey--Line 15	Form and Instruction	Modified	Available
Form 14 Child Mental Health--Line 14	Form and Instruction	Modified	Repair queued
Form 13 Teen Record Check--Line 13	Form and Instruction	Modified	Available
Form 12 Child Record Check--Line 12	Form and Instruction	Modified	Available
Form 11 Adult Quality of Life--Line 11	Form and Instruction	Modified	Available
Form 10 Adult Epilepsy--Line 10	Form and Instruction	Modified	Repair queued
Form 9 Adult Occupational Injury--Line 9	Form and Instruction	Modified	Available
Form 8 Child Cancer--Line 8	Form and Instruction	Modified	Available
updated NHIS 2011 Attachment 1.pdf	Supplementary Document	Uploaded 2010-12-13	Available
NHIS 83 C 2011 Supporting Statement new questions V2 083110.doc	Justification for No Material/Nonsubstantive Change	Uploaded 2010-09-01	Repair queued
NHIS 2010 Attachment 3n NHIS 2010 Flashcard Booklet.doc	Supplementary Document	Uploaded 2009-10-14	Available
Attachment4 Cover.doc	Supplementary Document	Uploaded 2008-08-07	Repair queued
Attachment3 Cover.doc	Supplementary Document	Uploaded 2008-08-07	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
45692	Adult Cancer--Line 7	Form and Instruction	Modified
45691	Family Disability--Line 6	Form and Instruction	Modified
45690	Child and Adult Immunization--Line 5	Form and Instruction	Modified
45689	Child Core--line 4	Form and Instruction	Modified
45688	Adult Core--line 3	Form and Instruction	Modified
45687	Family Core - line 2	Form and Instruction	Modified
37725	Screener Questionnaire--Line 1	Form and Instruction	Modified
191073	Reinterview Survey--Line 15	Form and Instruction	Modified
191072	Child Mental Health--Line 14	Form and Instruction	Modified
191071	Teen Record Check--Line 13	Form and Instruction	Modified
191070	Child Record Check--Line 12	Form and Instruction	Modified
191069	Adult Quality of Life--Line 11	Form and Instruction	Modified
191068	Adult Epilepsy--Line 10	Form and Instruction	Modified
186085	Adult Occupational Injury--Line 9	Form and Instruction	Modified
186084	Child Cancer--Line 8	Form and Instruction	Modified

ICR Details

OMB Control No: 0920-0214	ICR Reference No: 201009-0920-002
Status: Historical Active	Previous ICR Reference No: 200910-0920-008
Agency/Subagency: HHS/CDC	Agency Tracking No:
Title: National Health Interview Survey
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 12/13/2010
	Date Received in OIRA: 09/20/2010
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2013	01/31/2013	01/31/2013
Responses	220,400	0	220,400
Time Burden (Hours)	34,977	0	34,977
Cost Burden (Dollars)	0	0	0

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Abstract: The annual National Health Interview Survey (NHIS) is a major source of general statistics on the health of the U.S. population and has been in the field every year since 1957. This household-based survey collects demographic and health-related information on a nationally representative sample of households throughout the country. This request is to cycle out questions on cancer, occupational injury, and other topics fielded in 2010, and to cycle in questions on health care reform, food security, fitness center use, veteran status, income, and food stamps for 2011.

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Authorizing Statute(s): PL: Pub.L. 101 - 445 301 Name of Law: The National Nutrition Monitoring and Related Research Act of 1990
   PL: Pub.L. 104 - 170 136 Name of Law: The Food Quality Protection Act of 1996
   US Code: 42 USC 242 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

Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 15

table that charts list of burden

IC Title	Form No.	Form Name
Screener Questionnaire--Line 1	1	OMB Statement and Screener Section of the
Family Core - line 2	2	Family Core - line 2
Child and Adult Immunization--Line 5	5	Child and Adult Immunization--Line 5
Family Disability--Line 6	6	Family Disability--Line 6
Adult Cancer--Line 7	7	Adult Cancer--Line 7
Child Cancer--Line 8	8	Child Cancer--Line 8
Adult Occupational Injury--Line 9	9	Child cancer--Line 8
Adult Epilepsy--Line 10	10	Adult Epilepsy--Line 10
Adult Quality of Life--Line 11	11	Adult Quality of Life--Line 11
Child Record Check--Line 12	12	Child Record Check--Line 12
Teen Record Check--Line 13	13	Teen Record Check--Line 13
Child Mental Health--Line 14	14	Child Mental Health--Line 14
Adult Core--line 3	3	Adult Core--line3
Child Core--line 4	4	Child Core--line 4
Reinterview Survey--Line 15	15	Reinterview Survey--Line 15

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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	220,400	220,400	0	0	0	0
Annual Time Burden (Hours)	34,977	34,977	0	0	0	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: $31,000,000

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]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

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: 09/20/2010

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