Information Collection

Cognitive testing of High-impact, Chronic Pain questions - NCHS Questionnaire Design Research Laboratory (QDRL)

IC 215959 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⚠️ Notice: This information collection may be referencing outdated material.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

Document Name Document Type
Cognitive testing of High-impact, Chronic Pain questions - NCHS Questionnaire Design Research Laboratory (QDRL) Form and Instruction
Telephone Screener Attach 3 - Phone Screener - Pain.docx Form and Instruction
Pain Questionnaire to be evaluated Attach 1 - Qnne - Pain changes2 032615.docx Form and Instruction
0920-0222 QDRL Pain ltr 033015.docx NCHS QDRL Request (Letter to M. Schwab) IC Document
Attach 2 - Adflyer - Pain.docx Advertisement - Participants Wanted for Research Study IC Document
Attach 4 - Informed Consent - Pain 032615.docx Informed Consent Form 1 on 1 Interviews IC Document
Attach 5 - Special Consent -Pain.docx Special Consent - Use of Video/Audio Recordings IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Cognitive testing of High-impact, Chronic Pain questions - NCHS Questionnaire Design Research Laboratory (QDRL)	Agency IC Tracking Number:	0920-0222-15YY

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	Telephone Screener	Attach 3 - Phone Screener - Pain.docx	None	Yes	Yes	Fillable Fileable
Form and Instruction	None	Pain Questionnaire to be evaluated	Attach 1 - Qnne - Pain changes2 032615.docx	None	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title: 09-20-0164 Health and Demographic Surveys Conducted in Probability Samples of the U. S. Population	FR Citation: 49 FR 37693

Number of Respondents: 112	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	112	112
Annual IC Time Burden (Hours)	46	46
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
NCHS QDRL Request (Letter to M. Schwab)	0920-0222 QDRL Pain ltr 033015.docx	04/03/2015
Advertisement - Participants Wanted for Research Study	Attach 2 - Adflyer - Pain.docx	04/03/2015
Informed Consent Form 1 on 1 Interviews	Attach 4 - Informed Consent - Pain 032615.docx	04/03/2015
Special Consent - Use of Video/Audio Recordings	Attach 5 - Special Consent -Pain.docx	04/03/2015

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