Information Collection

Cognitive Interviews for Questionnaire Redesign

IC 199783 under ICR 201103-0930-001 · OMB 0930-0290.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0930-0290 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Protocol and Specs Cognitive Interviews for Questionnaire Redesign	Form and Instruction
Protocol and Specs Protocol and Specs Attachment E - Protocol and Specs_revised.docx	Form and Instruction
Attachment A - Cognitive Recruitment Flyers.doc Cognitive Recruitment Flyers	IC Document
Attachment B - Recruitment Screening Scripts.docx Recruitment Screening Scripts	IC Document
Attachment C - Participant Consent and Assent Forms.doc Participant Consent and Assent Forms	IC Document
Attachment D - Parental Permission Form.docx Parental Permission Form	IC Document
Attachment F - Cognitive Receipt for Participation.doc Cognitive Receipt for Participation	IC Document
SubmitMemo.doc Transmittal Letter	IC Document
OMB Supporting Statement_11.6.11.docx Supporting Statement	IC Document

IC Title:

Cognitive Interviews for Questionnaire Redesign

Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	Protocol and Specs	Protocol and Specs	Attachment E - Protocol and Specs_revised.docx		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 50

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	50	50
Annual IC Time Burden (Hours)	66	66
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Cognitive Recruitment Flyers	Attachment A - Cognitive Recruitment Flyers.doc	10/05/2011
Recruitment Screening Scripts	Attachment B - Recruitment Screening Scripts.docx	10/05/2011
Participant Consent and Assent Forms	Attachment C - Participant Consent and Assent Forms.doc	10/05/2011
Parental Permission Form	Attachment D - Parental Permission Form.docx	10/05/2011
Cognitive Receipt for Participation	Attachment F - Cognitive Receipt for Participation.doc	10/05/2011
Transmittal Letter	SubmitMemo.doc	10/05/2011
Supporting Statement	OMB Supporting Statement_11.6.11.docx	10/06/2011

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