2013 NHIS Health Insurance Web and Cognitive Interview Study

NCHS Questionnaire Design Research Laboratory

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0222 can be found here:

Documents and Forms

Document Name Document Type
Form 4 2013 NHIS Health Insurance Web and Cognitive Interview Study Form and Instruction
Attachment 1b - HE Cog Interview Guide.docx Instruction
Screener Attachment 3a, &b - HE Cog Int Telephone Screeners.docx Form and Instruction
4 Questionnaire Attachment 4 - Screen Shots of the Revised HE Web Questionnaire.docx Form and Instruction
Attachment 2 - HE Cog Int Adv.docx Study Advertisement IC Document
HE OMB 10 Day Letter.docx Letter to Dr. Schwab IC Document
Revised revAttachment 1a - HE Web Questionnaire.docx Word Version of Questionnaire IC Document

Information Collection (IC) Details

IC Title:	2013 NHIS Health Insurance Web and Cognitive Interview Study	Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	4	Questionnaire	Attachment 4 - Screen Shots of the Revised HE Web Questionnaire.docx	Yes	Yes	Fillable Fileable
Form and Instruction	none	Screener	Attachment 3a, &b - HE Cog Int Telephone Screeners.docx	Yes	No	Fillable Fileable
Instruction			Attachment 1b - HE Cog Interview Guide.docx	No	No	Printable Only

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records
Title: Health and Demographic Surveys Conducted in Probability Samples of the US Population	FR Citation: 49 FR 37693

Number of Respondents: 1,550	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	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	1,550	0	0	0	0	0
Annual IC Time Burden (Hours)	300	0	0	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
Study Advertisement	Attachment 2 - HE Cog Int Adv.docx	10/17/2013
Letter to Dr. Schwab	HE OMB 10 Day Letter.docx	10/17/2013
Word Version of Questionnaire	Revised revAttachment 1a - HE Web Questionnaire.docx	11/04/2013

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.