Information Collection

Adult Study Participants (baseline only + 1 retest)

IC 197918 under ICR 201105-0925-006 · OMB 0925-0638.

Documents and Forms

Documents and forms in this information collection
Document NameDocument Type
Form 2
Hearing Handicap Inventory (HHI) Adult Study Participants (baseline only + 1 retest)
Form and Instruction
Form 1
Automated Audiometry from the NIH Toolbox (AANT) Adult Study Participants (baseline only + 1 retest)
Form and Instruction
Form 6
University of Penn Smell Identification Adult Study Participants (baseline only + 1 retest)
Form and Instruction
Form 3
Words in Noise Adult Study Participants (baseline only + 1 retest)
Form and Instruction
Form 4
Ordor Identification Adult Study Participants (baseline only + 1 retest)
Form and Instruction
Form 10
PA Ages 18-85 Adult Study Participants (baseline only + 1 retest)
Form and Instruction
Form 11
Sucrose Preference Test Adult Study Participants (baseline only + 1 retest)
Form and Instruction
Form 12
Toolbox Taste Test Adult Study Participants (baseline only + 1 retest)
Form and Instruction
Form 13
Dynamic Visual Acuity (DVA) Adult Study Participants (baseline only + 1 retest)
Form and Instruction
Form 14
Vision Health Related QOL Survey Adult Study Participants (baseline only + 1 retest)
Form and Instruction
Form 15
Brief Kinesthesia Test Adult Study Participants (baseline only + 1 retest)
Form and Instruction
Form 17
Tactile Discrimination Test Adult Study Participants (baseline only + 1 retest)
Form and Instruction
Form 18
Dimensional Card Change Sort Adult Study Participants (baseline only + 1 retest)
Form and Instruction
Form 19
Bateria III Picture Vocabulary (Spanish only) Adult Study Participants (baseline only + 1 retest)
Form and Instruction
Form 20
Imitation Based Assessment of Memory Adult Study Participants (baseline only + 1 retest)
Form and Instruction
Form 22
List Sorting Adult Study Participants (baseline only + 1 retest)
Form and Instruction
Form 23
Oral Symbol Digit Modalities Adult Study Participants (baseline only + 1 retest)
Form and Instruction
Form 24
Pattern Comparison Adult Study Participants (baseline only + 1 retest)
Form and Instruction
Form 26
Reading Recognition Adult Study Participants (baseline only + 1 retest)
Form and Instruction
Form 27
Handedness Assessment Adult Study Participants (baseline only + 1 retest)
Form and Instruction
Form 28
Vocabulary Comprehension Adult Study Participants (baseline only + 1 retest)
Form and Instruction
Form 29
Word Accentuation (Spanish only) Adult Study Participants (baseline only + 1 retest)
Form and Instruction
Form 31
Emotional Health Questionaire Adult Study Participants (baseline only + 1 retest)
Form and Instruction
Form 32
Supplemental Emotional Health Questionaire Adult Study Participants (baseline only + 1 retest)
Form and Instruction
Form 33
Dexterity 9-hole Pegboard Adult Study Participants (baseline only + 1 retest)
Form and Instruction
Form 34
Endurance 2-Minute Walk Test Adult Study Participants (baseline only + 1 retest)
Form and Instruction
Form 35
Locomotion 4-meter Walk Test Adult Study Participants (baseline only + 1 retest)
Form and Instruction
Form 36
Grip Strength Dynamometry Adult Study Participants (baseline only + 1 retest)
Form and Instruction
Form 37
Strength Knee Extension Adult Study Participants (baseline only + 1 retest)
Form and Instruction
Form 38
Balance Accelerometer Measure Adult Study Participants (baseline only + 1 retest)
Form and Instruction
Form 39
Initial Adult Questionaire Adult Study Participants (baseline only + 1 retest)
Form and Instruction
Form 41
Additional Somatosensation Questions Adult Study Participants (baseline only + 1 retest)
Form and Instruction
Form 42
Additional Audition Olfaction Taste Adult Study Participants (baseline only + 1 retest)
Form and Instruction
Form 43
Cognition Information Form Adult Study Participants (baseline only + 1 retest)
Form and Instruction
Form 44
Health Care Access and Utilization Adult Study Participants (baseline only + 1 retest)
Form and Instruction
Form 45
Instrumental Activities of Daily Living Adult Study Participants (baseline only + 1 retest)
Form and Instruction
Form 46
Applied Cognition Adult Adult Study Participants (baseline only + 1 retest)
Form and Instruction
Form 52
PROMIS 29 Participant Adult Study Participants (baseline only + 1 retest)
Form and Instruction
Form 57
EtOH (Alcohol) Questionaire Adult Study Participants (baseline only + 1 retest)
Form and Instruction
Form 58
Education Adult Self-Report Adult Study Participants (baseline only + 1 retest)
Form and Instruction
Form 59
Education Proxy Report for Children Adult Study Participants (baseline only + 1 retest)
Form and Instruction
Form 55
Text Anxiety Scale Adult Study Participants (baseline only + 1 retest)
Form and Instruction
Form 56
Falls Efficscy Scale-International Adult Study Participants (baseline only + 1 retest)
Form and Instruction
Attach 30 Instructions for Emotional Health Questionnaire.pdf Instruction
2 Hearing Handicap Inventory (HHI)
Attach 2 Hearing Handicap Inventory.pdf
Form and Instruction
1 Automated Audiometry from the NIH Toolbox (AANT)
Attach 1 Automated Audiometry for the NIH Toolbox (AANT).pdf
Form and Instruction
6 University of Penn Smell Identification
Attach 6 University of Pennsylvania Smell Identification Test (UPSIT).pdf
Form and Instruction
3 Words in Noise
Attach 3 Words-In-Noise Test (WIN).pdf
Form and Instruction
4 Ordor Identification
Attach 4 Odor Identification Ages 10-85.pdf
Form and Instruction
10 PA Ages 18-85
Attach 10 Pain Assessment Ages 18-85.pdf
Form and Instruction
11 Sucrose Preference Test
Attach 11 Sucrose Preference Test.pdf
Form and Instruction
12 Toolbox Taste Test
Attach 12 Toolbox Taste Test.pdf
Form and Instruction
13 Dynamic Visual Acuity (DVA)
Attach 13 Dynamic Visual Acuity (DVA).pdf
Form and Instruction
14 Vision Health Related QOL Survey
Attach 14 Vision Health-Related Quality of Life Survey.pdf
Form and Instruction
15 Brief Kinesthesia Test
Attach 15 Brief Kinesthesia Test.pdf
Form and Instruction
17 Tactile Discrimination Test
Attach 17 Tactile Discrimination Test.pdf
Form and Instruction
18 Dimensional Card Change Sort
Attach 18 Dimensional Change Card Sort.pdf
Form and Instruction
19 Bateria III Picture Vocabulary (Spanish only)
Attach 19 Bateria III Picture Vocabulary.pdf
Form and Instruction
20 Imitation Based Assessment of Memory
Attach 20 Flanker.pdf
Form and Instruction
22 List Sorting
Attach 22 List Sorting.pdf
Form and Instruction
23 Oral Symbol Digit Modalities
Attach 23 Oral Symbol Digit Modalities Test.pdf
Form and Instruction
24 Pattern Comparison
Attach 24 Pattern Comparison.pdf
Form and Instruction
26 Reading Recognition
Attach 26 Reading Recognition.pdf
Form and Instruction
27 Handedness Assessment
Attach 27 Determining Handedness.pdf
Form and Instruction
28 Vocabulary Comprehension
Attach 28 Vocabulary Comprehension.pdf
Form and Instruction
29 Word Accentuation (Spanish only)
Attach 29 Spanish Word Accentuation Test.pdf
Form and Instruction
31 Emotional Health Questionaire
Attach 31 Emotional Health Questionnaires for Toolbox.xlsx
Form and Instruction
32 Supplemental Emotional Health Questionaire
Attach 32 Supplemental Emotional Health Questionnaires.xls
Form and Instruction
33 Dexterity 9-hole Pegboard
Attach 33 9 Hole Pegboard.pdf
Form and Instruction
34 Endurance 2-Minute Walk Test
Attach 34 Endurance 2 Minute Walk Test (2MWT).pdf
Form and Instruction
35 Locomotion 4-meter Walk Test
Attach 35 Locomotion 4 Meter Walk Test.pdf
Form and Instruction
36 Grip Strength Dynamometry
Attach 36 Grip Strength Dynamometry.pdf
Form and Instruction
37 Strength Knee Extension
Attach 37 Strength Knee Extension.pdf
Form and Instruction
38 Balance Accelerometer Measure
Attach 38 Balance Accelerometer Measure (BAM).pdf
Form and Instruction
39 Initial Adult Questionaire
Attach 39 Initial Questionnaire - Adult.pdf
Form and Instruction
41 Additional Somatosensation Questions
Attach 41 Additional Somatosensation Questions.pdf
Form and Instruction
42 Additional Audition Olfaction Taste
Attach 42 Additional Audition Olfaction Taste Questions.pdf
Form and Instruction
43 Cognition Information Form
Attach 43 Cognition Information Form.pdf
Form and Instruction
44 Health Care Access and Utilization
Attach 44 Health Care Access and Utilization.pdf
Form and Instruction
45 Instrumental Activities of Daily Living
Attach 45 Instrumental Activities of Daily Living (IADL) - Adults.pdf
Form and Instruction
46 Applied Cognition Adult
Attach 46 Applied Cognition - Adults.xlsx
Form and Instruction
52 PROMIS 29 Participant
Attach 52 PROMIS 29 - Participant.pdf
Form and Instruction
57 EtOH (Alcohol) Questionaire
Attach 57 EtOH Questionnaire.pdf
Form and Instruction
58 Education Adult Self-Report
Attach 58 Education Adult Self-Report.pdf
Form and Instruction
59 Education Proxy Report for Children
Attach 59 Education Proxy Report for Children.pdf
Form and Instruction
55 Text Anxiety Scale
Attach 55 Test Anxiety Scale (TAS).pdf
Form and Instruction
56 Falls Efficscy Scale-International
Attach 56 Falls Efficacy Scale-International (Short FES-I).pdf
Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

layout table

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 2 Yes Yes Fillable Fileable
Form and Instruction 1 Yes Yes Fillable Fileable
Form and Instruction 6 Yes Yes Fillable Fileable
Form and Instruction 3 Yes Yes Fillable Fileable
Form and Instruction 4 Yes Yes Fillable Fileable
Form and Instruction 10 Yes Yes Fillable Fileable
Form and Instruction 11 Yes Yes Fillable Fileable
Form and Instruction 12 Yes Yes Fillable Fileable
Form and Instruction 13 No Yes Fillable Fileable
Form and Instruction 14 Yes Yes Fillable Fileable
Form and Instruction 15 Yes Yes Fillable Fileable
Form and Instruction 17 Yes Yes Fillable Fileable
Form and Instruction 18 Yes Yes Fillable Fileable
Form and Instruction 19 Yes Yes Fillable Fileable
Form and Instruction 20 Yes Yes Fillable Fileable
Form and Instruction 22 Yes Yes Fillable Fileable
Form and Instruction 23 Yes Yes Paper Only
Form and Instruction 24 Yes Yes Fillable Fileable
Form and Instruction 26 Yes Yes Fillable Fileable
Form and Instruction 27 Yes Yes Fillable Fileable
Form and Instruction 28 Yes Yes Fillable Fileable
Form and Instruction 29 Yes Yes Fillable Fileable
Instruction Yes Yes Fillable Fileable
Form and Instruction 31 Yes Yes Fillable Fileable
Form and Instruction 32 Yes Yes Fillable Fileable
Form and Instruction 33 Yes Yes Fillable Fileable
Form and Instruction 34 Yes Yes Fillable Fileable
Form and Instruction 35 Yes Yes Fillable Fileable
Form and Instruction 36 Yes Yes Fillable Fileable
Form and Instruction 37 Yes Yes Fillable Fileable
Form and Instruction 38 Yes Yes Fillable Fileable
Form and Instruction 39 Yes Yes Fillable Fileable
Form and Instruction 41 Yes Yes Fillable Fileable
Form and Instruction 42 Yes Yes Fillable Fileable
Form and Instruction 43 Yes Yes Fillable Fileable
Form and Instruction 44 Yes Yes Fillable Fileable
Form and Instruction 45 Yes Yes Fillable Fileable
Form and Instruction 46 Yes Yes Fillable Fileable
Form and Instruction 52 Yes Yes Fillable Fileable
Form and Instruction 57 No No Fillable Fileable
Form and Instruction 58 Yes Yes Fillable Fileable
Form and Instruction 59 Yes Yes Fillable Fileable
Form and Instruction 55 Yes Yes Fillable Fileable
Form and Instruction 56 Yes Yes Fillable Fileable

Federal Enterprise Architecture Business Reference Module


table that charts list of burden
  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 5,850 0 5,850 0 0 0
Annual IC Time Burden (Hours) 17,550 0 17,550 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Documents for IC
table that charts IC Documents
Title Document Date Uploaded
No associated records found
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.
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