Teen Disability and Demographic Questions Cognitive Interviewing 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⚠️ Notice: This information collection may be referencing outdated material.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
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

Information Collection (IC) Details

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:

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 %

	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

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.