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Cognitive testing of High-impact, Chronic Pain questions - NCHS Questionnaire Design Research Laboratory (QDRL)
NCHS Questionnaire Design Research Laboratory
OMB: 0920-0222
IC ID: 215959
OMB.report
HHS/CDC
OMB 0920-0222
ICR 201205-0920-001
IC 215959
( )
⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0222 can be found here:
2022-12-21 - Revision of a currently approved collection
2021-08-16 - Revision of a currently approved collection
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
Federal Enterprise Architecture Business Reference Module
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 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
112
0
112
0
0
0
Annual IC Time Burden (Hours)
46
0
46
0
0
0
Annual IC Cost Burden (Dollars)
0
0
0
0
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.