National Health Interview Survey

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 3g Child Immunization Provider--NHIS Instrument Spec Report	Form and Instruction	Modified	Available
Form 3e National Health Interview Provider Survey--Teen	Form and Instruction	Modified	Available
Form 3d Child Record Check--Immunization History Questionnaire	Form and Instruction	Modified	Available
Form 3c 2011 NHIS Questionnaire--Sample Child	Form and Instruction	Modified	Available
Form 3b Adult Core	Form and Instruction	Modified	Available
Form 3a Family Core	Form and Instruction	Modified	Available
Form 1 OMB Statement and Screener Section of the	Form and Instruction	Modified	Available
Form 15 Reinterview Survey--Line 15	Form and Instruction	Removed	Available
Form 14 Child Mental Health--Line 14	Form and Instruction	Removed	Available
Form 13 Teen Record Check--Line 13	Form and Instruction	Removed	Available
Form 12 Child Record Check--Line 12	Form and Instruction	Removed	Available
Form 11 Adult Quality of Life--Line 11	Form and Instruction	Removed	Available
Form 10 Adult Epilepsy--Line 10	Form and Instruction	Removed	Available
Form 3h 2011 NHIS Reinterview Instrument Screens	Form and Instruction	Modified	Available
Form 3f Family Health Insurance--Health Care Reform	Form and Instruction	Modified	Repair queued
NHIS 2011-2013 Sup Stat B new version 061611.doc	Supporting Statement B	Uploaded 2011-07-19	Available
PLAW-111publ152.pdf	Supplementary Document	Uploaded 2011-07-20	Available
ACA DOCUMENT_PLAW-111publ148.pdf	Supplementary Document	Uploaded 2011-07-20	Available
Attachment 5c Research Ethics Review Board Approval.docx	Supplementary Document	Uploaded 2011-07-20	Available
Attachment 5b 60-day comments and response.docx	Supplementary Document	Uploaded 2011-07-20	Available
Attachment 5a Advance Letter.pdf	Supplementary Document	Uploaded 2011-07-20	Available
Attachment 4c BSC Review Panel Report.doc	Supplementary Document	Uploaded 2011-07-20	Available
Attachment 4b Review Panel Roster.doc	Supplementary Document	Uploaded 2011-07-20	Available
Attachment 4a Consultants for 1997 Redesign.doc	Supplementary Document	Uploaded 2011-07-20	Available
Attachment 3i NHIS 2011 Flashcard Booklet.pdf	Supplementary Document	Uploaded 2011-07-20	Available
NHIS 2010 Attachment 3n NHIS 2010 Flashcard Booklet.doc	Supplementary Document	Uploaded 2009-10-14	Repair queued
Attachment4 Cover.doc	Supplementary Document	Uploaded 2008-08-07	Available
NHIS 2011-2013 Sup Stat A new version 070711.doc	Supporting Statement A	Uploaded 2011-07-19	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
45692	National Health Interview Survey--Line 7	Form and Instruction	Modified	Child Immunization Provider--NHIS Instrument Spec Report
45691	Teen Record Check--Line 6	Form and Instruction	Modified	National Health Interview Provider Survey--Teen
45690	Child Record Check--Line 5	Form and Instruction	Modified	Child Record Check--Immunization History Questionnaire
45689	Child Core--line 4	Form and Instruction	Modified	2011 NHIS Questionnaire--Sample Child
45688	Adult Core--line 3	Form and Instruction	Modified	Adult Core
45687	Family Core - line 2	Form and Instruction	Modified	Family Core
37725	Screener Questionnaire--Line 1	Form and Instruction	Modified	OMB Statement and Screener Section of the
191073	Reinterview Survey--Line 15	Form and Instruction	Removed	Reinterview Survey--Line 15
191072	Child Mental Health--Line 14	Form and Instruction	Removed	Child Mental Health--Line 14
191071	Teen Record Check--Line 13	Form and Instruction	Removed	Teen Record Check--Line 13
191070	Child Record Check--Line 12	Form and Instruction	Removed	Child Record Check--Line 12
191069	Adult Quality of Life--Line 11	Form and Instruction	Removed	Adult Quality of Life--Line 11
191068	Adult Epilepsy--Line 10	Form and Instruction	Removed	Adult Epilepsy--Line 10
186085	Reinterview Survey--Line 9	Form and Instruction	Modified	2011 NHIS Reinterview Instrument Screens
186084	Supplements--Line 8	Form and Instruction	Modified	Family Health Insurance--Health Care Reform

ICR Details

OMB Control No: 0920-0214	ICR Reference No: 201107-0920-008
Status: Historical Active	Previous ICR Reference No: 201009-0920-002
Agency/Subagency: HHS/CDC	Agency Tracking No:
Title: National Health Interview Survey
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 08/25/2011
Retrieve Notice of Action (NOA)	Date Received in OIRA: 07/26/2011
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2014	36 Months From Approved	01/31/2013
Responses	212,940	0	220,400
Time Burden (Hours)	55,343	0	34,977
Cost Burden (Dollars)	0	0	0

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Abstract: The annual NCHS National Health Interview Survey (NHIS) is a major source of general statistics on the health of the U.S. population and has been in the field every year since 1957. This household-based survey collects demographic and health-related information on a nationally representative sample of households throughout the country. This request is to extend data collection and to increase the sample size for 2011, 2012, and 2013.

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Authorizing Statute(s): PL: Pub.L. 104 - 170 136 Name of Law: The Food Quality Protection Act of 1996
   PL: Pub.L. 101 - 445 301 Name of Law: The National Nutrition Monitoring and Related Research Act of 1990
   US Code: 42 USC 242 Name of Law: Public Health Service Act
   US Code: 42 USC 306 Name of Law: Public Health Service Act
   PL: Pub.L. 111 - 148 1 Name of Law: The Patient Protection and Affordable Care Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	75 FR 39533	07/09/2010
30-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 44337	07/25/2011
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 9

table that charts list of burden

IC Title	Form No.	Form Name
Adult Core--line 3	3b	Adult Core
Adult Epilepsy--Line 10	10	Adult Epilepsy--Line 10
Adult Quality of Life--Line 11	11	Adult Quality of Life--Line 11
Child Core--line 4	3c	2011 NHIS Questionnaire--Sample Child
Child Mental Health--Line 14	14	Child Mental Health--Line 14
Child Record Check--Line 12	12	Child Record Check--Line 12
Child Record Check--Line 5	3d	Child Record Check--Immunization History Questionnaire
Family Core - line 2	3a	Family Core
National Health Interview Survey--Line 7	3g	Child Immunization Provider--NHIS Instrument Spec Report
Reinterview Survey--Line 15	15	Reinterview Survey--Line 15
Reinterview Survey--Line 9	3h	2011 NHIS Reinterview Instrument Screens
Screener Questionnaire--Line 1	1	OMB Statement and Screener Section of the
Supplements--Line 8	3f	Family Health Insurance--Health Care Reform
Teen Record Check--Line 13	13	Teen Record Check--Line 13
Teen Record Check--Line 6	3e	National Health Interview Provider Survey--Teen

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ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	212,940	220,400	0	-7,460	0	0
Annual Time Burden (Hours)	55,343	34,977	0	20,366	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: The total number of respondents and burden hours is higher because the sample size has been increased to provide more state-level estimates

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Annual Cost to Federal Government: $31,000,000

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Yes

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 07/26/2011

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