Information Collection

Sub-study #3_Health Information National Trends Survey 4 (HINTS 4) Cognitive Testing of Cycle 2 Instrument

IC 200806 under ICR 201302-0925-007 · OMB 0925-0589.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0589 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 2 Sub-study #3_Health Information National Trends Survey 4 (HINTS 4) Cognitive Testing of Cycle 2 Instrument	Form and Instruction
2 HINTS Cycle 2 Cognitive Interview Protocol #3_AttachB_Cycle 2 Cog Interview Protocol 1-13-2012.doc	Form and Instruction
1 HINTS Cycle 2 Questionnaire #3_AttachA_HINTS_Cycle 2 Qx_1-12-2012.doc	Form and Instruction
3 HINTS Cycle 2 Screener #3_AttachE_HINTS_Cycle 2_Screener.docx	Form and Instruction
#3_Justif_MemoAttachments_C_D_F_G_HINTS_Cycle2_01-12-12.DOC #3_Justif_MemoAttachments_C_D_F_G_HINTS_Cycle2_01-12-12	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Sub-study #3_Health Information National Trends Survey 4 (HINTS 4) Cognitive Testing of Cycle 2 Instrument

Agency IC Tracking Number:

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	2	HINTS Cycle 2 Cognitive Interview Protocol	#3_AttachB_Cycle 2 Cog Interview Protocol 1-13-2012.doc	No	No	Printable Only
Form and Instruction	1	HINTS Cycle 2 Questionnaire	#3_AttachA_HINTS_Cycle 2 Qx_1-12-2012.doc	No	No	Printable Only
Form and Instruction	3	HINTS Cycle 2 Screener	#3_AttachE_HINTS_Cycle 2_Screener.docx	No	No	Printable Only

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title: SORN #09-25-0156, "Records of Participants in Programs and Respondents in Surveys Used to Evaluate Programs of the Public Health Service, HHS/PHS/NIH/OD"

FR Citation: 67 FR 60743

Number of Respondents: 93

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Previously Approved
Annual Number of Responses for this IC	93	93
Annual IC Time Burden (Hours)	65	65
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
#3_Justif_MemoAttachments_C_D_F_G_HINTS_Cycle2_01-12-12	#3_Justif_MemoAttachments_C_D_F_G_HINTS_Cycle2_01-12-12.DOC	02/27/2013

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