Information Collection

Cognitive Testing of the MEPS Cancer SAQ

IC 197779 under ICR 201104-0935-002 · OMB 0935-0124.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
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

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:

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	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 %

table that charts list of burden
	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

table that charts IC Documents
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.