Information Collection

Sub-study #9_Health Information National Trends Survey 4 (HINTS 4) Cog Test of Cycle 4 (Revised)

IC 210410 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⚠️ Notice: This information collection may be referencing outdated material.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

Document Name Document Type
Form 1 Sub-study #9_Health Information National Trends Survey 4 (HINTS 4) Cog Test of Cycle 4 (Revised) Form and Instruction
1 Screener - Revised - English Attach E-1_Screener English-REV_2-10-2014.docx Form and Instruction
2 Screener - Revised - Spanish Attach E-2_Screener Spanish-REV_2-10-2014.docx Form and Instruction
3 Consent Form - English Attach C-1_Consent Form English-REV.docx Form and Instruction
4 Consent Form - Spanish Attach C-2_Consent Form Spanish-REV.docx Form and Instruction
5 Interview Protocol - English Attach B-1_Protocol English-revised.docx Form and Instruction
6 Interview Protocol - Spanish Attach B-2_Protocol Spanish-revised.docx Form and Instruction
Attach A-1_Instrument-to-be-tested_English-REV.docx Attach A-1_Instrument-to-be-tested_English-REV IC Document
Attach A-2_Instrument-to-be-tested_Spanish-REV.docx Attach A-2_Instrument-to-be-tested_Spanish-REV 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 letter.pdf Attach G - IRB approval letter IC Document
Justif Memo revised 02-11-14.doc Justif Memo revised 02-11-14 IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Sub-study #9_Health Information National Trends Survey 4 (HINTS 4) Cog Test of Cycle 4 (Revised)	Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	1	Screener - Revised - English	Attach E-1_Screener English-REV_2-10-2014.docx	No	No	Printable Only
Form and Instruction	2	Screener - Revised - Spanish	Attach E-2_Screener Spanish-REV_2-10-2014.docx	No	No	Printable Only
Form and Instruction	3	Consent Form - English	Attach C-1_Consent Form English-REV.docx	No	No	Printable Only
Form and Instruction	4	Consent Form - Spanish	Attach C-2_Consent Form Spanish-REV.docx	No	No	Printable Only
Form and Instruction	5	Interview Protocol - English	Attach B-1_Protocol English-revised.docx	No	No	Printable Only
Form and Instruction	6	Interview Protocol - Spanish	Attach B-2_Protocol Spanish-revised.docx	No	No	Printable Only

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 126	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	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	126	0	0	0	0	0
Annual IC Time Burden (Hours)	68	0	0	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
Attach A-1_Instrument-to-be-tested_English-REV	Attach A-1_Instrument-to-be-tested_English-REV.docx	02/10/2014
Attach A-2_Instrument-to-be-tested_Spanish-REV	Attach A-2_Instrument-to-be-tested_Spanish-REV.docx	02/10/2014
Attach D_Advertisements	Attach D_Advertisements.docx	02/10/2014
Attach F_Reminder Letter	Attach F_Reminder Letter.docx	02/10/2014
Attach G - IRB approval letter	Attach G - IRB approval letter.pdf	02/10/2014
Justif Memo revised 02-11-14	Justif Memo revised 02-11-14.doc	02/11/2014

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