Sub-study #3_Health Information National Trends Survey 4 (HINTS 4) Cognitive Testing of Cycle 2 Instrument

Questionnaire Cognitive Interviewing and Pretesting (NCI)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0589 can be found here:

Documents and Forms

Document Name Document Type
Form 2 Sub-study #3_Health Information National Trends Survey 4 (HINTS 4) Cognitive Testing of Cycle 2 Instrument Form and Instruction
1 HINTS Cycle 2 Questionnaire #3_AttachA_HINTS_Cycle 2 Qx_1-12-2012.doc Form and Instruction
3 HINTS Cycle 2 Screener #3_AttachE_HINTS_Cycle 2_Screener.docx Form and Instruction
2 HINTS Cycle 2 Cognitive Interview Protocol #3_AttachB_Cycle 2 Cog Interview Protocol 1-13-2012.doc Form and Instruction
#3_Justif_MemoAttachments_C_D_F_G_HINTS_Cycle2_01-12-12.DOC Justification Memo & Attachments C, D, F, and G HINTS Cycle 2 IC Document

Information Collection (IC) Details

IC Title:	Sub-study #3_Health Information National Trends Survey 4 (HINTS 4) Cognitive Testing of Cycle 2 Instrument	Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	2	HINTS Cycle 2 Cognitive Interview Protocol	#3_AttachB_Cycle 2 Cog Interview Protocol 1-13-2012.doc	Yes	No	Printable Only
Form and Instruction	1	HINTS Cycle 2 Questionnaire	#3_AttachA_HINTS_Cycle 2 Qx_1-12-2012.doc	Yes	No	Printable Only
Form and Instruction	3	HINTS Cycle 2 Screener	#3_AttachE_HINTS_Cycle 2_Screener.docx	No	Yes	Printable Only

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title: SORN #09-25-0156, "Records of Participants in Programs and Respondents in Surveys Used to Evaluate Programs of the Public Health Service, HHS/PHS/NIH/OD"	FR Citation: 67 FR 60743

Number of Respondents: 93	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	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	93	0	0	0	0	0
Annual IC Time Burden (Hours)	65	0	0	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
Justification Memo & Attachments C, D, F, and G HINTS Cycle 2	#3_Justif_MemoAttachments_C_D_F_G_HINTS_Cycle2_01-12-12.DOC	01/12/2012

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