Questionnaire Cognitive Interviewing and Pretesting (NCI)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 1 Screener (English)	Form and Instruction	New	Available
Form 4 Interview Protocol (Spanish)	Form and Instruction	New	Available
Form 3 Interview Protocol (English)	Form and Instruction	New	Available
Form 2 Screener (Spanish)	Form and Instruction	New	Available
Form 7 Teen Cognitive Interview Guide	Form and Instruction	New	Available
Form 6 Parent Cognitive Interview Guide	Form and Instruction	New	Available
Form 5 Teen Physical Activity Survey and Recall	Form and Instruction	New	Available
Form 4 Teen Diet and Demographic Survey	Form and Instruction	New	Available
Form 3 Parent Physical Activity Survey and Checklist	Form and Instruction	New	Available
Form 2 Parent Diet and Demographic Survey	Form and Instruction	New	Available
Form 1 FLASHE Screener	Form and Instruction	New	Repair queued
Form 2 HINTS Cycle 2 Cognitive Interview Protocol	Form and Instruction	New	Available
Form 3 HINTS Cycle 2 Screener	Form and Instruction	New	Available
Form 1 HINTS Cycle 2 Questionnaire	Form and Instruction	New	Available
Form 1 #1_ASA 24 Screener and Guide	Form and Instruction	New	Available
Form 2 #2_GEM Attach 2C 2D Survey and Guide	Form and Instruction	New	Available
SSB_0925-0589_2010 12-9-10.doc	Supporting Statement B	Uploaded 2011-02-15	Available
Attach 3_Privacy Act Memo.pdf	Supplementary Document	Uploaded 2011-02-15	Available
Attach 2_Cognitive Interviewing.doc	Supplementary Document	Uploaded 2011-02-15	Available
Attach 1_Approved and Potential Gen ICs.pdf	Supplementary Document	Uploaded 2011-02-15	Available
Cover Letter_Generic 2010.doc	Supplementary Document	Uploaded 2011-02-15	Available
SSA_0925-0589_2-2-11.doc	Supporting Statement A	Uploaded 2011-02-15	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
205099	Sub-study #5: Health Information National Trends Survey 4 (HINTS 4) Cognitive Testing of Cycle 3 Instrument	Form and Instruction	New	Screener (English)
205099	Sub-study #5: Health Information National Trends Survey 4 (HINTS 4) Cognitive Testing of Cycle 3 Instrument	Form and Instruction	New	Interview Protocol (Spanish)
205099	Sub-study #5: Health Information National Trends Survey 4 (HINTS 4) Cognitive Testing of Cycle 3 Instrument	Form and Instruction	New	Interview Protocol (English)
205099	Sub-study #5: Health Information National Trends Survey 4 (HINTS 4) Cognitive Testing of Cycle 3 Instrument	Form and Instruction	New	Screener (Spanish)
202800	Sub-study #4: Cognitive Testing of the Family Life, Activity, Sun, Health, and Eating (FLASHE) Survey	Form and Instruction	New	Teen Cognitive Interview Guide
202800	Sub-study #4: Cognitive Testing of the Family Life, Activity, Sun, Health, and Eating (FLASHE) Survey	Form and Instruction	New	Parent Cognitive Interview Guide
202800	Sub-study #4: Cognitive Testing of the Family Life, Activity, Sun, Health, and Eating (FLASHE) Survey	Form and Instruction	New	Teen Physical Activity Survey and Recall
202800	Sub-study #4: Cognitive Testing of the Family Life, Activity, Sun, Health, and Eating (FLASHE) Survey	Form and Instruction	New	Teen Diet and Demographic Survey
202800	Sub-study #4: Cognitive Testing of the Family Life, Activity, Sun, Health, and Eating (FLASHE) Survey	Form and Instruction	New	Parent Physical Activity Survey and Checklist
202800	Sub-study #4: Cognitive Testing of the Family Life, Activity, Sun, Health, and Eating (FLASHE) Survey	Form and Instruction	New	Parent Diet and Demographic Survey
202800	Sub-study #4: Cognitive Testing of the Family Life, Activity, Sun, Health, and Eating (FLASHE) Survey	Form and Instruction	New	FLASHE Screener
200806	Sub-study #3_Health Information National Trends Survey 4 (HINTS 4) Cognitive Testing of Cycle 2 Instrument	Form and Instruction	New	HINTS Cycle 2 Cognitive Interview Protocol
200806	Sub-study #3_Health Information National Trends Survey 4 (HINTS 4) Cognitive Testing of Cycle 2 Instrument	Form and Instruction	New	HINTS Cycle 2 Screener
200806	Sub-study #3_Health Information National Trends Survey 4 (HINTS 4) Cognitive Testing of Cycle 2 Instrument	Form and Instruction	New	HINTS Cycle 2 Questionnaire
198056	Bundled Website Usability Testings #1 (ASA24) and #2 (GEM)	Form and Instruction	New	#1_ASA 24 Screener and Guide
198056	Bundled Website Usability Testings #1 (ASA24) and #2 (GEM)	Form and Instruction	New	#2_GEM Attach 2C 2D Survey and Guide

ICR Details

OMB Control No: 0925-0589	ICR Reference No: 201103-0925-004
Status: Historical Active	Previous ICR Reference No: 201008-0925-003
Agency/Subagency: HHS/NIH	Agency Tracking No:
Title: Questionnaire Cognitive Interviewing and Pretesting (NCI)
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: 04/19/2011
Retrieve Notice of Action (NOA)	Date Received in OIRA: 03/18/2011
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	04/30/2014	36 Months From Approved	05/31/2011
Responses	3,600	0	1,200
Time Burden (Hours)	3,600	0	1,200
Cost Burden (Dollars)	0	0	0

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Abstract: A generic clearance is requested from OMB for general questionnaire development and pretesting activities to be carried out in 2011-2014 by the staff of the Applied Research Program, in the Division of Cancer Control and Population Sciences. Four types of activities will be carried out: survey questionnaire development and pretesting based on cognitive interviewing methodology, research on the cognitive aspects of survey methodology, research on computer-user interface design for computer-assisted instruments (including Web-based surveys), also known as Usability Testing, and Pilot Household interviews.

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Authorizing Statute(s): US Code: 42 USC 412 Name of Law: Public Health Service Act
   US Code: 42 USC 410 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:
	75 FR 79009	12/17/2010
30-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 12979	03/09/2011
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 4

table that charts list of burden

IC Title	Form No.	Form Name
Bundled Website Usability Testings #1 (ASA24) and #2 (GEM)	2, 1	#2_GEM Attach 2C 2D Survey and Guide ,   #1_ASA 24 Screener and Guide
Sub-study #3_Health Information National Trends Survey 4 (HINTS 4) Cognitive Testing of Cycle 2 Instrument	2, 1, 3	HINTS Cycle 2 Questionnaire ,   HINTS Cycle 2 Screener ,   HINTS Cycle 2 Cognitive Interview Protocol
Sub-study #4: Cognitive Testing of the Family Life, Activity, Sun, Health, and Eating (FLASHE) Survey	1, 2, 3, 4, 5, 6, 7	FLASHE Screener ,   Parent Diet and Demographic Survey ,   Parent Physical Activity Survey and Checklist ,   Teen Diet and Demographic Survey ,   Teen Physical Activity Survey and Recall ,   Parent Cognitive Interview Guide ,   Teen Cognitive Interview Guide
Sub-study #5: Health Information National Trends Survey 4 (HINTS 4) Cognitive Testing of Cycle 3 Instrument	2, 3, 4, 1	Screener (Spanish) ,   Interview Protocol (English) ,   Interview Protocol (Spanish) ,   Screener (English)

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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	3,600	1,200	0	0	2,400	0
Annual Time Burden (Hours)	3,600	1,200	0	0	2,400	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: $244,000

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: 03/18/2011

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