Information Collection

Sub-study #5: Health Information National Trends Survey 4 (HINTS 4) Cognitive Testing of Cycle 3 Instrument

IC 205099 under ICR 201103-0925-004 · OMB 0925-0589.

⚠️ Notice: This information collection may be referencing outdated material.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 #5: Health Information National Trends Survey 4 (HINTS 4) Cognitive Testing of Cycle 3 Instrument Form and Instruction
2 Screener (Spanish) Attach E-2_Screener Spanish.docx Form and Instruction
3 Interview Protocol (English) Attach B-1_Interview Protocol in English.docx Form and Instruction
4 Interview Protocol (Spanish) Attach B-2_Interview Protocol in Spanish.docx Form and Instruction
1 Screener (English) Attach E-1_Screener English.docx Form and Instruction
Attach C-2_Consent Form Spanish.docx Attach C-2_Consent Form Spanish IC Document
Justif Memo 12-5-12.doc Justif Memo 12-5-12 IC Document
Attach C-1_Consent Form English.docx Attach C-1_Consent Form English IC Document
Attach D_Advertisements.docx Attach D_Advertisements IC Document
Attach F_Reminder Letter.docx Attach F_Reminder Letter IC Document
Attach G_IRB Approval.pdf Attach G_IRB Approval IC Document
Attach A-1_Questionnaire to Test_English.docx Attach A-1_Questionnaire to Test_English IC Document
Attach A-2_Questionnaire to Test_Spanish.docx Attach A-2_Questionnaire to Test_Spanish IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Sub-study #5: Health Information National Trends Survey 4 (HINTS 4) Cognitive Testing of Cycle 3 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	Screener (Spanish)	Attach E-2_Screener Spanish.docx	Yes	No	Printable Only
Form and Instruction	3	Interview Protocol (English)	Attach B-1_Interview Protocol in English.docx	Yes	No	Printable Only
Form and Instruction	4	Interview Protocol (Spanish)	Attach B-2_Interview Protocol in Spanish.docx	Yes	No	Printable Only
Form and Instruction	1	Screener (English)	Attach E-1_Screener English.docx	Yes	No	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
Attach C-2_Consent Form Spanish	Attach C-2_Consent Form Spanish.docx	12/05/2012
Justif Memo 12-5-12	Justif Memo 12-5-12.doc	12/05/2012
Attach C-1_Consent Form English	Attach C-1_Consent Form English.docx	12/05/2012
Attach D_Advertisements	Attach D_Advertisements.docx	12/05/2012
Attach F_Reminder Letter	Attach F_Reminder Letter.docx	12/05/2012
Attach G_IRB Approval	Attach G_IRB Approval.pdf	12/05/2012
Attach A-1_Questionnaire to Test_English	Attach A-1_Questionnaire to Test_English.docx	12/05/2012
Attach A-2_Questionnaire to Test_Spanish	Attach A-2_Questionnaire to Test_Spanish.docx	12/05/2012

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