National Health Interview Survey

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Sexual Identity Module	Form	Modified	Available
Supplements	Form	Modified	Available
Child/Teen Record Check	Form	Modified	Available
Child Core	Form	Modified	Available
Adult Core	Form	Modified	Available
Family Core	Form	Modified	Available
Screener	Form	Modified	Available
Methodological sample frame test of 5,000 persons	Form	New	Available
Reinterview Survey	Form	Modified	Available
Multi-mode Study	Form	Modified	Available
Att8bOMB_advance_reminder_ty_letters2013NHCIS020813.docx	Supplementary Document	Uploaded 2013-03-04	Available
Att 8a NHCIS Flowchart rev12_14_12[1].pdf	Supplementary Document	Uploaded 2013-03-04	Available
UPDATE-Att 8 NHCIS protocol.doc	Supplementary Document	Uploaded 2013-03-04	Available
UPDAT-NHIS_2013-2015_SS_B_1127121 in ROCISorig.doc	Supporting Statement B	Uploaded 2013-03-04	Available
Attachment 3i NHIS 2013 Flashcard Booklet.pdf.pdf	Supplementary Document	Uploaded 2012-12-05	Available
Attachment 7 Comparison of Supplement Questions with Questions from Pas....docx	Supplementary Document	Uploaded 2012-12-05	Available
Attachment 5c Research Ethics Review Board Approval.docx	Supplementary Document	Uploaded 2012-12-05	Available
Attachment 5b 60-day Public Notice Comments and Response.docx	Supplementary Document	Uploaded 2012-12-05	Available
Attachment 5a Advance Letter.pdf	Supplementary Document	Uploaded 2012-12-05	Available
Attachment 4a Consultants for 1997 Redesign.doc	Supplementary Document	Uploaded 2012-12-05	Available
Attachment 2 Federal Register Notice of 60-day Public Comment Period.pdf.pdf	Supplementary Document	Uploaded 2012-12-05	Available
Attachment 1 Applicable Laws and Regulations.doc.doc	Supplementary Document	Uploaded 2012-12-05	Available
UPDAT-NHIS_2013-2015_SS_A_1127121.doc	Supporting Statement A	Uploaded 2013-03-04	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
45692	Sexual Identity Module--Line 7	Form	Modified	Sexual Identity Module
45691	Supplements--Line 6	Form	Modified	Supplements
45690	Child Record Check--Line 5	Form	Modified	Child/Teen Record Check
45689	Child Core--line 4	Form	Modified	Child Core
45688	Adult Core--line 3	Form	Modified	Adult Core
45687	Family Core - line 2	Form	Modified	Family Core
37725	Screener Questionnaire--Line 1	Form	Modified	Screener
205038	Sample Frame Test-line 10	Form	New	Methodological sample frame test of 5,000 persons
186085	Reinterview Survey--Line 9	Form	Modified	Reinterview Survey
186084	Multi-mode Study--Line 8	Form	Modified	Multi-mode Study

ICR Details

OMB Control No: 0920-0214	ICR Reference No: 201212-0920-003
Status: Historical Active	Previous ICR Reference No: 201209-0920-004
Agency/Subagency: HHS/CDC	Agency Tracking No:
Title: National Health Interview Survey
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 03/04/2013
Retrieve Notice of Action (NOA)	Date Received in OIRA: 12/06/2012
Terms of Clearance: NCHS should consult with OMB before submitting non-substantive change requests to ensure that the changes under consideration should be classified as such.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2016	36 Months From Approved	08/31/2014
Responses	257,000	0	212,940
Time Burden (Hours)	57,099	0	55,343
Cost Burden (Dollars)	0	0	0

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Abstract: The NCHS annual National Health Interview Survey (NHIS) is a major source of general statistics on the health of the U.S. population and has been in the field every year since 1957. This household-based survey collects demographic and health-related information on a nationally representative sample of households throughout the country. This revision seeks approval to continue the NHIS for 2013-2015, to cycle in questions on various topics including immune suppression, hepatitis B/C, and sexual identity. Permission is sought to conduct a web-based multimode follow-back survey of sample adult respondents from the 2012 survey.

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Authorizing Statute(s): US Code: 42 USC 242 Name of Law: Public Health Service Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 38295	06/27/2012
30-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 72867	12/06/2012
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 10

table that charts list of burden

IC Title	Form No.	Form Name
Adult Core--line 3	none	Adult Core
Child Core--line 4	none	Child Core
Child Record Check--Line 5	none	Child/Teen Record Check
Family Core - line 2	none	Family Core
Multi-mode Study--Line 8	none	Multi-mode Study
Reinterview Survey--Line 9	none	Reinterview Survey
Sample Frame Test-line 10	none	Methodological sample frame test of 5,000 persons
Screener Questionnaire--Line 1	none	Screener
Sexual Identity Module--Line 7	none	Sexual Identity Module
Supplements--Line 6	none	Supplements

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ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	257,000	212,940	0	44,060	0	0
Annual Time Burden (Hours)	57,099	55,343	0	1,756	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: The increase in burden is due to the addition of the multi-mode follow-back survey and the sample frame methodology study. Some survey modules have been cycled out while others are cycled in for the coming survey period.

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Annual Cost to Federal Government: $42,000,000

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Yes

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 12/06/2012

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