Information Collection

Sub-study #5: Health Information National Trends Survey 4 (HINTS 4) Cognitive Testing of Cycle 3 Instrument

IC 205099 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⚠️ Notice: This information collection may be referencing outdated material.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 3 Sub-study #5: Health Information National Trends Survey 4 (HINTS 4) Cognitive Testing of Cycle 3 Instrument	Form and Instruction
3 Interview Protocol (English) Attach B-1_Interview Protocol in English.docx	Form and Instruction
2 Screener (Spanish) Attach E-2_Screener Spanish.docx	Form and Instruction
4 Interview Protocol (Spanish) Attach B-2_Interview Protocol in Spanish.docx	Form and Instruction
1 Screener (English) Attach E-1_Screener English.docx	Form and Instruction
Attach C-1_Consent Form English.docx Attach C-1_Consent Form English	IC Document
Justif Memo 12-5-12.doc Justif Memo 12-5-12	IC Document
Attach A-1_Questionnaire to Test_English.docx Attach A-1_Questionnaire to Test_English	IC Document
Attach A-2_Questionnaire to Test_Spanish.docx Attach A-2_Questionnaire to Test_Spanish	IC Document
Attach C-2_Consent Form Spanish.docx Attach C-2_Consent Form Spanish	IC Document
Attach D_Advertisements.docx Attach D_Advertisements	IC Document
Attach F_Reminder Letter.docx Attach F_Reminder Letter	IC Document
Attach G_IRB Approval.pdf Attach G_IRB Approval	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Sub-study #5: Health Information National Trends Survey 4 (HINTS 4) Cognitive Testing of Cycle 3 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	3	Interview Protocol (English)	Attach B-1_Interview Protocol in English.docx	No	No	Printable Only
Form and Instruction	2	Screener (Spanish)	Attach E-2_Screener Spanish.docx	No	No	Printable Only
Form and Instruction	4	Interview Protocol (Spanish)	Attach B-2_Interview Protocol in Spanish.docx	No	No	Printable Only
Form and Instruction	1	Screener (English)	Attach E-1_Screener English.docx	Yes	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
Attach C-1_Consent Form English	Attach C-1_Consent Form English.docx	02/27/2013
Justif Memo 12-5-12	Justif Memo 12-5-12.doc	02/27/2013
Attach A-1_Questionnaire to Test_English	Attach A-1_Questionnaire to Test_English.docx	02/27/2013
Attach A-2_Questionnaire to Test_Spanish	Attach A-2_Questionnaire to Test_Spanish.docx	02/27/2013
Attach C-2_Consent Form Spanish	Attach C-2_Consent Form Spanish.docx	02/27/2013
Attach D_Advertisements	Attach D_Advertisements.docx	02/27/2013
Attach F_Reminder Letter	Attach F_Reminder Letter.docx	02/27/2013
Attach G_IRB Approval	Attach G_IRB Approval.pdf	02/27/2013

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