Cognitive Testing of the MEPS Cancer SAQ

Questionnaire and Data Collection Testing, Evaluation, and Research for the Agency for Healthcare Research and Quality

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0935-0124 can be found here:

Documents and Forms

Document Name Document Type
Form Form #1 Cognitive Testing of the MEPS Cancer SAQ Form and Instruction
Form #2 Cognitive Interview Guide Attachment C -- Cognitive Interview Guide 4-20-2011.docx Form and Instruction
Form #1 Screener Questionnaire Attachment B -- Screener Questionnaire 5-26-2011.docx Form and Instruction
Attachment D -- Draft Cancer SAQ 4-20-2011.docx Attachment D -- Draft Cancer SAQ 4-20-2011 IC Document
Supporting Statement Part B -- Cognitive Testing for Cancer SAQ 4-20-2011.docx Supporting Statement Part B -- Cognitive Testing for Cancer SAQ 4-20-2011 IC Document
Supporting Statement Part A -- Cognitive Testing for Cancer SAQ 5-26-2011.docx Supporting Statement Part A -- Cognitive Testing for Cancer SAQ 5-26-2011 IC Document
Attachment E -- Recruitment Advertisement 5-26-2011.doc Attachment E -- Recruitment Advertisement 5-26-2011 IC Document
Attachment F -- Consent Form 5-26-2011.doc Attachment F -- Consent Form 5-26-2011 IC Document

Information Collection (IC) Details

IC Title:	Cognitive Testing of the MEPS Cancer SAQ	Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	Form #1	Screener Questionnaire	Attachment B -- Screener Questionnaire 5-26-2011.docx		Yes	Yes	Paper Only
Form and Instruction	Form #2	Cognitive Interview Guide	Attachment C -- Cognitive Interview Guide 4-20-2011.docx		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 160	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	160	160
Annual IC Time Burden (Hours)	88	88
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Attachment D -- Draft Cancer SAQ 4-20-2011	Attachment D -- Draft Cancer SAQ 4-20-2011.docx	05/20/2011
Supporting Statement Part B -- Cognitive Testing for Cancer SAQ 4-20-2011	Supporting Statement Part B -- Cognitive Testing for Cancer SAQ 4-20-2011.docx	05/20/2011
Supporting Statement Part A -- Cognitive Testing for Cancer SAQ 5-26-2011	Supporting Statement Part A -- Cognitive Testing for Cancer SAQ 5-26-2011.docx	05/26/2011
Attachment E -- Recruitment Advertisement 5-26-2011	Attachment E -- Recruitment Advertisement 5-26-2011.doc	05/26/2011
Attachment F -- Consent Form 5-26-2011	Attachment F -- Consent Form 5-26-2011.doc	05/26/2011

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