Information Collection Request

NCHS Questionnaire Design Research Laboratory

ICR 201205-0920-001 · OMB 0920-0222 · Historical Active

Forms and Documents

Forms and supporting documents for this ICR
DocumentTypeStatusAvailability
Form 0920-0222 Questionnaire Design Research Lab (2016 NAMCS Culturally and Linguistically Appropriate Services (CLAS) Supplement Evaluation) Form and Instruction New Available
Cognitive testing of High-impact, Chronic Pain questions - NCHS Questionnaire Design Research Laboratory (QDRL) Form and Instruction New Available
Evaluate Cervical and Lung Cancer Screening Questions Form New Available
UNICEF/Washington Group School Environment Study Form New Repair queued
2015 National Electronic Health Records Survey Form New Available
Teen Disability and Demographic Questions Cognitive Interviewing Study Form and Instruction New Available
Diabetes Primary Prevention Form New Available
Cognitive Testing of Adults with Chronic Health Care Needs Form and Instruction New Available
NAMCS Feasibility Study Form and Instruction New Available
Pregnancy Risk Assessment Monitoring System Form New Available
Adult and Child Disability Questions Form and Instruction New Available
Form 4 2013 NHIS Health Insurance Web and Cognitive Interview Study Form and Instruction New Repair queued
GENERIC IC Gen IC Questionnaire Design Research Lab - 2013 Comparative Disability Questions and Mode Effects Study Form New Available
Testing Long-term Care Questions Form New Available
Evaluation of Uniform Donor History Questionnaire and Evaluation of Violence Against Children Survey (VACS)- Malawi Form and Instruction New Available
4 Sets of Health Questions and Blood Donor History Questionnaire Evaluation Form and Instruction New Repair queued
Violence Against Children Survey Evaluation Study - Philippines Form New Available
Questionnaire Design Research Lab: 5600 Case CAPI and ACASI NHIS Field Test Form and Instruction New Available
Supporting Statement B-0322 2012 updated B5.doc Supporting Statement B Uploaded 2012-05-08 Available
QDRL-OMB Attachment P ACASI Questions.doc Supplementary Document Uploaded 2012-05-08 Available
QDRL-OMB Attachment O Explain Cog Interview.doc Supplementary Document Uploaded 2012-05-08 Available
QDRL-OMB Attachment N Answer Mach Script.doc Supplementary Document Uploaded 2012-05-08 Available
QDRL-OMB Attachment M Newspaper Adv.doc Supplementary Document Uploaded 2012-05-08 Available
QDRL-OMB Attachment L Sample flyer.doc Supplementary Document Uploaded 2012-05-08 Available
QDRL-OMB Attachment K phone screeners.docx Supplementary Document Uploaded 2012-05-08 Available
QDRL-OMB Attachment J ERB approval.doc Supplementary Document Uploaded 2012-05-08 Available
QDRL-OMB Attachment I send Off site research.doc Supplementary Document Uploaded 2012-05-08 Available
QDRL-OMB Attachment H Spec Consent for FG.docx Supplementary Document Uploaded 2012-05-08 Available
QDRL-OMB Attachment G Spec Consent.docx Supplementary Document Uploaded 2012-05-08 Available
QDRL-OMB Attachment F Cash Payment Receipt.doc Supplementary Document Uploaded 2012-05-08 Available
QDRL-OMB Attachment E Resp Data Collect Sheet.doc Supplementary Document Uploaded 2012-05-08 Available
QDRL-OMB Attachment D informed consent.doc Supplementary Document Uploaded 2012-05-08 Available
QDRL-OMB Attachment C Advance letter.doc Supplementary Document Uploaded 2012-05-08 Available
QDRL-OMB Attachment B2 Comments received on 60-day notice.docx Supplementary Document Uploaded 2012-05-08 Repair queued
QDRL-OMB Attachment B1 Federal Register Notice.pdf Supplementary Document Uploaded 2012-05-08 Available
QDRL-OMB Attachment A Pub Health Serv Act.docx Supplementary Document Uploaded 2012-05-08 Available
Supporting Statement A-final 032212.doc Supporting Statement A Uploaded 2012-05-08 Available

IC Document Collections

Information collection document groups
IC IDCollectionTypeStatusForm
216469 Questionnaire Design Research Lab (2016 NAMCS Culturally and Linguistically Appropriate Services (CLAS) Supplement Evaluation) Form and Instruction New
215959 Cognitive testing of High-impact, Chronic Pain questions - NCHS Questionnaire Design Research Laboratory (QDRL) Form and Instruction New
215946 Evaluate Cervical and Lung Cancer Screening Questions Form New
215509 UNICEF/Washington Group School Environment Study Form New
215492 2015 National Electronic Health Records Survey Form New
215142 NHIS College Housing Frame Questionnaire Study Other-WORD New
214970 Teen Disability and Demographic Questions Cognitive Interviewing Study Form and Instruction New
214369 Diabetes Primary Prevention Form New
212592 Cognitive Testing of Adults with Chronic Health Care Needs Form and Instruction New
211558 NAMCS Feasibility Study Form and Instruction New
211406 Pregnancy Risk Assessment Monitoring System Form New
210607 2015 NHIS Occupational Health Supplement and Cancer Control Supplement Other-WORD New
209941 Adult and Child Disability Questions Form and Instruction New
208996 2013 NHIS Health Insurance Web and Cognitive Interview Study Form and Instruction New
207913 GENERIC IC Gen IC Questionnaire Design Research Lab - 2013 Comparative Disability Questions and Mode Effects Study Form New
207399 Testing Long-term Care Questions Form New
204892 Evaluation of Uniform Donor History Questionnaire and Evaluation of Violence Against Children Survey (VACS)- Malawi Form and Instruction New
203563 4 Sets of Health Questions and Blood Donor History Questionnaire Evaluation Form and Instruction New
203170 Violence Against Children Survey Evaluation Study - Philippines Form New
202862 Questionnaire Design Research Lab: 5600 Case CAPI and ACASI NHIS Field Test Form and Instruction New

ICR Details

Reginfo record details
table that charts list comparision
  Inventory as of this Action Requested Previously Approved
06/30/2015 36 Months From Approved 03/31/2013
9,300 0 850
9,450 0 1,800
0 0 0





Reginfo record details
20
table that charts list of burden
IC Title Form No. Form Name
Evaluation of Uniform Donor History Questionnaire and Evaluation of Violence Against Children Survey (VACS)- Malawi None, None, None Attachment 1 Uniform Donor History Questionnaire ,   What to do when a loved one dies-A survivor's checklist ,   Attachment 1: Violence Against Children Survey - Malawi: Age 13-24 years
4 Sets of Health Questions and Blood Donor History Questionnaire Evaluation none, none Four Sets of Health Related Questions ,   Blood Donor History Questionnaire
Cognitive Testing of Adults with Chronic Health Care Needs none Adults with Chronic Health Care Needs
Evaluate Cervical and Lung Cancer Screening Questions none, none Screener ,   Questionnaire
Cognitive testing of High-impact, Chronic Pain questions - NCHS Questionnaire Design Research Laboratory (QDRL) None, None Telephone Screener ,   Pain Questionnaire to be evaluated
2015 NHIS Occupational Health Supplement and Cancer Control Supplement none, none Cancer Control - Questionniare ,   Cancer Control - screener
Testing Long-term Care Questions none, none, none NSLTP - Adult Day Services Center ,   NSLTP - Residential Care Community ,   Screeners
Violence Against Children Survey Evaluation Study - Philippines none Violence Against Children Survey
2013 NHIS Health Insurance Web and Cognitive Interview Study none, 4 Questionnaire ,   Screener
NAMCS Feasibility Study none, none, none Physician Survey ,   Medical Organization Survey ,   Phys and Organization Survey
GENERIC IC Gen IC Questionnaire Design Research Lab - 2013 Comparative Disability Questions and Mode Effects Study None, None, None Attachment 1a: WHO Questionnaire ,   Attachment 1b: Washington Group Questionnaire ,   Attachments 3a & 3b--Telephone Screeners
Adult and Child Disability Questions none, none, none Screening Script ,   Adult Disability Questions ,   Child Disability Questions
UNICEF/Washington Group School Environment Study none, none Questionnaire ,   Screener
NHIS College Housing Frame Questionnaire Study
Questionnaire Design Research Lab: 5600 Case CAPI and ACASI NHIS Field Test none, none Proposed ACASI Questions ,   HIS-100C, January 2011 Manual for NHIS Field Reps Explaning the Survey
Questionnaire Design Research Lab (2016 NAMCS Culturally and Linguistically Appropriate Services (CLAS) Supplement Evaluation) 0920-0222, 0920-0222 Attach 1 Q8 050615 (2) ,   Attach 3 - CLAS Phone screener
Teen Disability and Demographic Questions Cognitive Interviewing Study none, none Questionnaire ,   Screener
Diabetes Primary Prevention none, none Questionnaire ,   Screener
2015 National Electronic Health Records Survey none, none, none National Electronic Health Records Survey 2015 ,   Screener ,   Respondent Data Sheet
Pregnancy Risk Assessment Monitoring System none, none, none, none PRAMS Phase 8 ,   Screener ,   Consent ,   Respondent Data

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 9,300 850 0 0 8,450 0
Annual Time Burden (Hours) 9,450 1,800 0 0 7,650 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0


Reginfo record details
  No