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Questionnaire Design Research Lab (2016 NAMCS Culturally and Linguistically Appropriate Services (CLAS) Supplement Evaluation)
NCHS Questionnaire Design Research Laboratory
OMB: 0920-0222
IC ID: 216469
OMB.report
HHS/CDC
OMB 0920-0222
ICR 201205-0920-001
IC 216469
( )
⚠️ Notice: This information collection may be referencing outdated material.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
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
Federal Enterprise Architecture Business Reference Module
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 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
68
0
68
0
0
0
Annual IC Time Burden (Hours)
24
0
24
0
0
0
Annual IC Cost Burden (Dollars)
0
0
0
0
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.