Information Collection

Cognitive Testing of Adults with Chronic Health Care Needs

IC 212592 under ICR 201205-0920-001 · OMB 0920-0222.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Cognitive Testing of Adults with Chronic Health Care Needs	Form and Instruction
Adults with Chronic Health Care Needs 0920-0222 QDRL ACHCN Attach 1 Resp Screener Instrument 072414.docx	Form and Instruction
0920-0222 QDRL ACHCN letter072914.docx Letter to Dr. Schwab	IC Document
0920-0222 QDRL ACHCN Attach2abc Adv.docx Advertisements	IC Document

IC Title:

Cognitive Testing of Adults with Chronic Health Care Needs

Agency IC Tracking Number:

14ARU

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	none	Adults with Chronic Health Care Needs	0920-0222 QDRL ACHCN Attach 1 Resp Screener Instrument 072414.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

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: 60

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	60	60
Annual IC Time Burden (Hours)	60	60
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Letter to Dr. Schwab	0920-0222 QDRL ACHCN letter072914.docx	08/06/2014
Advertisements	0920-0222 QDRL ACHCN Attach2abc Adv.docx	08/06/2014

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