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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
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

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:

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	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 %

table that charts list of burden
	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

table that charts IC Documents
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.