NCHS Questionnaire Design Research Laboratory

Forms and Documents

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

IC Document Collections

IC ID	Document Title	Status
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

OMB Control No: 0920-0222	ICR Reference No: 201205-0920-001
Status: Historical Active	Previous ICR Reference No: 201002-0920-006
Agency/Subagency: HHS/CDC	Agency Tracking No:
Title: NCHS Questionnaire Design Research Laboratory
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: 06/13/2012
	Date Received in OIRA: 05/10/2012
Terms of Clearance: CDC will continue to submit individual collections under this generic clearance to OMB. OMB will strive to provide feedback on the individual collections within ten working days, whenever possible, as is currently the case. Standard remuneration of respondents for congantive testing is $40.00. Higher remunerations may be requested with justification for difficult recruitments, focus groups, etc.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2015	36 Months From Approved	03/31/2013
Responses	9,300	0	850
Time Burden (Hours)	9,450	0	1,800
Cost Burden (Dollars)	0	0	0

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Abstract: This submission describes proposed research activities of the National Center for Health Statistics (NCHS) Questionnaire Design Research Laboratory. Survey specific research activities include questionnaire development, pre-testing, and evaluation activities for NCHS, CDC, other federal agencies, or other academic or professional institutions. The purpose and use of collecting this information fall into five categories: 1) Development and testing of specific survey questionnaires; 2) Research on the cognitive and interpretive aspects of survey methodology; 3) Research on human-computer interfaces/usability; 4) Field tests/Pilot interviewing; and 5) Studies of the optimal design and presentation of statistical graphical and textual material. Methods for data collection include interviewer administered, self-administered, telephone, Computer Assisted Personal Interviewing (CAPI) and Computer Assisted Self-Interviewing (CASI), Audio Computer-Assisted Self-Interviewing (ACASI), and web-based questionnaires including: cognitive interviewing, focus groups, usability testing, and field tests/pilot household interviews.

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Authorizing Statute(s): US Code: 42 USC 242k Name of Law: Public Health Service 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:
	77 FR 11124	02/24/2012
30-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 27064	05/08/2012
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 20

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

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ICR Summary 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

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $1,571,700

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]? No

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: 05/10/2012

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