Information Collection

Questionnaire Design Research Lab (2016 NAMCS Culturally and Linguistically Appropriate Services (CLAS) Supplement Evaluation)

IC 216469 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⚠️ Notice: This information collection may be referencing outdated material.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
Form 0920-0222 Questionnaire Design Research Lab (2016 NAMCS Culturally and Linguistically Appropriate Services (CLAS) Supplement Evaluation) Form and Instruction
0920-0222 Attach 1 Q8 050615 (2) Attach 1 Q8 050615 (2).docx Form and Instruction
0920-0222 Attach 3 - CLAS Phone screener Attach 3 - CLAS Phone screener.docx Form and Instruction
CLAS 10day letter 041015.docx CLAS 10day letter 041015 IC Document
Attach 5 - CLAS Resp data sheet.docx Attach 5 - CLAS Resp data sheet IC Document
Attach 2 - CLAS Advance letter.doc Attach 2 - CLAS Advance letter IC Document
Attach 4 - CLAS Informed consent.docx Attach 4 - CLAS Informed consent IC Document
Attach 6 - CLAS Special consent.docx Attach 6 - CLAS Special consent IC Document
Attach 7 - CLAS Thank you letter.docx Attach 7 - CLAS Thank you letter IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Questionnaire Design Research Lab (2016 NAMCS Culturally and Linguistically Appropriate Services (CLAS) Supplement Evaluation)	Agency IC Tracking Number:	15AEM

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	0920-0222	Attach 1 Q8 050615 (2)	Attach 1 Q8 050615 (2).docx		Yes	Yes	Fillable Fileable
Form and Instruction	0920-0222	Attach 3 - CLAS Phone screener	Attach 3 - CLAS Phone screener.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 68	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	68	68
Annual IC Time Burden (Hours)	24	24
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
CLAS 10day letter 041015	CLAS 10day letter 041015.docx	05/07/2015
Attach 5 - CLAS Resp data sheet	Attach 5 - CLAS Resp data sheet.docx	05/07/2015
Attach 2 - CLAS Advance letter	Attach 2 - CLAS Advance letter.doc	05/07/2015
Attach 4 - CLAS Informed consent	Attach 4 - CLAS Informed consent.docx	05/07/2015
Attach 6 - CLAS Special consent	Attach 6 - CLAS Special consent.docx	05/07/2015
Attach 7 - CLAS Thank you letter	Attach 7 - CLAS Thank you letter.docx	05/07/2015

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