Information Collection

Teen Disability and Demographic Questions Cognitive Interviewing Study

IC 214970 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⚠️ Notice: This information collection may be referencing outdated material.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
Teen Disability and Demographic Questions Cognitive Interviewing Study	Form and Instruction
Questionnaire Attachment 1ab - Qnne 011915.docx	Form and Instruction
Screener Attachment 3 - Screener-cleancopy.docx	Form and Instruction
0920-0222 QDRL letter Disability.docx Letter to Dr. Schwab	IC Document
Attachment 2a-c Adv&Flyers.docx Recruitment Flyers	IC Document
Attachment 4a&b - Informed consent-assent.docx Consent	IC Document
Attachment 5 - special consent.docx Special Consent	IC Document

IC Title:

Teen Disability and Demographic Questions Cognitive Interviewing Study

Agency IC Tracking Number:

15OW

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	Questionnaire	Attachment 1ab - Qnne 011915.docx		Yes	Yes	Fillable Fileable
Form and Instruction	none	Screener	Attachment 3 - Screener-cleancopy.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

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: 200

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	200	200
Annual IC Time Burden (Hours)	100	100
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 letter Disability.docx	02/12/2015
Recruitment Flyers	Attachment 2a-c Adv&Flyers.docx	02/12/2015
Consent	Attachment 4a&b - Informed consent-assent.docx	02/12/2015
Special Consent	Attachment 5 - special consent.docx	02/12/2015

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