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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
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

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:

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	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 %

table that charts list of burden
	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

table that charts IC Documents
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.