NCHS Questionnaire Design Research Laboratory

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 0920-0222 Attach 3 - CLAS Phone screener	Form and Instruction	New	Available
Form 0920-0222 Attach 1 Q8 050615 (2)	Form and Instruction	New	Available
Pain Questionnaire to be evaluated	Form and Instruction	New	Available
Telephone Screener	Form and Instruction	New	Available
Questionnaire	Form	New	Available
Screener	Form	New	Available
Screener	Form	New	Available
Questionnaire	Form	New	Repair queued
Respondent Data Sheet	Form	New	Available
Screener	Form and Instruction	New	Available
National Electronic Health Records Survey 2015	Form	New	Available
Screener	Form and Instruction	New	Available
Questionnaire	Form and Instruction	New	Available
Screener	Form	New	Available
Questionnaire	Form	New	Available
Adults with Chronic Health Care Needs	Form and Instruction	New	Available
Phys and Organization Survey	Form and Instruction	New	Available
Medical Organization Survey	Form and Instruction	New	Available
Physician Survey	Form and Instruction	New	Available
Respondent Data	Form	New	Available
Consent	Form	New	Available
Screener	Form and Instruction	New	Available
PRAMS Phase 8	Form	New	Available
Cancer Control - screener	Form	New	Available
Cancer Control - Questionniare	Form	New	Available
Child Disability Questions	Form	New	Available
Adult Disability Questions	Form	New	Available
Screening Script	Form and Instruction	New	Available
Form 4 Questionnaire	Form and Instruction	New	Available
Screener	Form and Instruction	New	Available
Attachments 3a & 3b--Telephone Screeners	Form and Instruction	New	Available
Attachment 1b: Washington Group Questionnaire	Form	New	Available
Attachment 1a: WHO Questionnaire	Form	New	Available
Screeners	Form and Instruction	New	Available
NSLTP - Residential Care Community	Form	New	Available
NSLTP - Adult Day Services Center	Form	New	Available
Attachment 1: Violence Against Children Survey - Malawi: Age 13-24 years	Form	New	Available
What to do when a loved one dies-A survivor's checklist	Form	New	Available
Attachment 1 Uniform Donor History Questionnaire	Form and Instruction	New	Available
Blood Donor History Questionnaire	Form and Instruction	New	Available
Four Sets of Health Related Questions	Form and Instruction	New	Available
Violence Against Children Survey	Form	New	Available
HIS-100C, January 2011 Manual for NHIS Field Reps Explaning the Survey	Form and Instruction	New	Available
Proposed ACASI Questions	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 ID	Collection	Type	Status	Form
216469	Questionnaire Design Research Lab (2016 NAMCS Culturally and Linguistically Appropriate Services (CLAS) Supplement Evaluation)	Form and Instruction	New	Attach 3 - CLAS Phone screener
216469	Questionnaire Design Research Lab (2016 NAMCS Culturally and Linguistically Appropriate Services (CLAS) Supplement Evaluation)	Form and Instruction	New	Attach 1 Q8 050615 (2)
215959	Cognitive testing of High-impact, Chronic Pain questions - NCHS Questionnaire Design Research Laboratory (QDRL)	Form and Instruction	New	Pain Questionnaire to be evaluated
215959	Cognitive testing of High-impact, Chronic Pain questions - NCHS Questionnaire Design Research Laboratory (QDRL)	Form and Instruction	New	Telephone Screener
215946	Evaluate Cervical and Lung Cancer Screening Questions	Form	New	Questionnaire
215946	Evaluate Cervical and Lung Cancer Screening Questions	Form	New	Screener
215509	UNICEF/Washington Group School Environment Study	Form	New	Screener
215509	UNICEF/Washington Group School Environment Study	Form	New	Questionnaire
215492	2015 National Electronic Health Records Survey	Form	New	Respondent Data Sheet
215492	2015 National Electronic Health Records Survey	Form and Instruction	New	Screener
215492	2015 National Electronic Health Records Survey	Form	New	National Electronic Health Records Survey 2015
215142	NHIS College Housing Frame Questionnaire Study	Other-WORD	New
214970	Teen Disability and Demographic Questions Cognitive Interviewing Study	Form and Instruction	New	Screener
214970	Teen Disability and Demographic Questions Cognitive Interviewing Study	Form and Instruction	New	Questionnaire
214369	Diabetes Primary Prevention	Form	New	Screener
214369	Diabetes Primary Prevention	Form	New	Questionnaire
212592	Cognitive Testing of Adults with Chronic Health Care Needs	Form and Instruction	New	Adults with Chronic Health Care Needs
211558	NAMCS Feasibility Study	Form and Instruction	New	Phys and Organization Survey
211558	NAMCS Feasibility Study	Form and Instruction	New	Medical Organization Survey
211558	NAMCS Feasibility Study	Form and Instruction	New	Physician Survey
211406	Pregnancy Risk Assessment Monitoring System	Form	New	Respondent Data
211406	Pregnancy Risk Assessment Monitoring System	Form	New	Consent
211406	Pregnancy Risk Assessment Monitoring System	Form and Instruction	New	Screener
211406	Pregnancy Risk Assessment Monitoring System	Form	New	PRAMS Phase 8
210607	2015 NHIS Occupational Health Supplement and Cancer Control Supplement	Form	New	Cancer Control - screener
210607	2015 NHIS Occupational Health Supplement and Cancer Control Supplement	Form	New	Cancer Control - Questionniare
210607	2015 NHIS Occupational Health Supplement and Cancer Control Supplement	Other-WORD	New
209941	Adult and Child Disability Questions	Form	New	Child Disability Questions
209941	Adult and Child Disability Questions	Form	New	Adult Disability Questions
209941	Adult and Child Disability Questions	Form and Instruction	New	Screening Script
208996	2013 NHIS Health Insurance Web and Cognitive Interview Study	Form and Instruction	New	Questionnaire
208996	2013 NHIS Health Insurance Web and Cognitive Interview Study	Form and Instruction	New	Screener
208996	2013 NHIS Health Insurance Web and Cognitive Interview Study	Instruction	New
207913	GENERIC IC Gen IC Questionnaire Design Research Lab - 2013 Comparative Disability Questions and Mode Effects Study	Form and Instruction	New	Attachments 3a & 3b--Telephone Screeners
207913	GENERIC IC Gen IC Questionnaire Design Research Lab - 2013 Comparative Disability Questions and Mode Effects Study	Form	New	Attachment 1b: Washington Group Questionnaire
207913	GENERIC IC Gen IC Questionnaire Design Research Lab - 2013 Comparative Disability Questions and Mode Effects Study	Form	New	Attachment 1a: WHO Questionnaire
207399	Testing Long-term Care Questions	Form and Instruction	New	Screeners
207399	Testing Long-term Care Questions	Form	New	NSLTP - Residential Care Community
207399	Testing Long-term Care Questions	Form	New	NSLTP - Adult Day Services Center
204892	Evaluation of Uniform Donor History Questionnaire and Evaluation of Violence Against Children Survey (VACS)- Malawi	Form	New	Attachment 1: Violence Against Children Survey - Malawi: Age 13-24 years
204892	Evaluation of Uniform Donor History Questionnaire and Evaluation of Violence Against Children Survey (VACS)- Malawi	Form	New	What to do when a loved one dies-A survivor's checklist
204892	Evaluation of Uniform Donor History Questionnaire and Evaluation of Violence Against Children Survey (VACS)- Malawi	Form and Instruction	New	Attachment 1 Uniform Donor History Questionnaire
203563	4 Sets of Health Questions and Blood Donor History Questionnaire Evaluation	Form and Instruction	New	Blood Donor History Questionnaire
203563	4 Sets of Health Questions and Blood Donor History Questionnaire Evaluation	Form and Instruction	New	Four Sets of Health Related Questions
203170	Violence Against Children Survey Evaluation Study - Philippines	Form	New	Violence Against Children Survey
202862	Questionnaire Design Research Lab: 5600 Case CAPI and ACASI NHIS Field Test	Form and Instruction	New	HIS-100C, January 2011 Manual for NHIS Field Reps Explaning the Survey
202862	Questionnaire Design Research Lab: 5600 Case CAPI and ACASI NHIS Field Test	Form and Instruction	New	Proposed ACASI Questions

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
Retrieve Notice of Action (NOA)	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.

table that charts list comparision

	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

table that charts list of burden

IC Title	Form No.	Form Name
2013 NHIS Health Insurance Web and Cognitive Interview Study	none, 4	Screener ,   Questionnaire
2015 NHIS Occupational Health Supplement and Cancer Control Supplement	none, none	Cancer Control - Questionniare ,   Cancer Control - screener
2015 National Electronic Health Records Survey	none, none, none	National Electronic Health Records Survey 2015 ,   Screener ,   Respondent Data Sheet
4 Sets of Health Questions and Blood Donor History Questionnaire Evaluation	none, none	Four Sets of Health Related Questions ,   Blood Donor History Questionnaire
Adult and Child Disability Questions	none, none, none	Screening Script ,   Adult Disability Questions ,   Child Disability Questions
Cognitive Testing of Adults with Chronic Health Care Needs	none	Adults with Chronic Health Care Needs
Cognitive testing of High-impact, Chronic Pain questions - NCHS Questionnaire Design Research Laboratory (QDRL)	None, None	Telephone Screener ,   Pain Questionnaire to be evaluated
Diabetes Primary Prevention	none, none	Questionnaire ,   Screener
Evaluate Cervical and Lung Cancer Screening Questions	none, none	Screener ,   Questionnaire
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
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
NAMCS Feasibility Study	none, none, none	Physician Survey ,   Medical Organization Survey ,   Phys and Organization Survey
NHIS College Housing Frame Questionnaire Study
Pregnancy Risk Assessment Monitoring System	none, none, none, none	PRAMS Phase 8 ,   Screener ,   Consent ,   Respondent Data
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
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
Teen Disability and Demographic Questions Cognitive Interviewing Study	none, none	Questionnaire ,   Screener
Testing Long-term Care Questions	none, none, none	NSLTP - Adult Day Services Center ,   NSLTP - Residential Care Community ,   Screeners
UNICEF/Washington Group School Environment Study	none, none	Questionnaire ,   Screener
Violence Against Children Survey Evaluation Study - Philippines	none	Violence Against Children Survey

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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	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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