National Health Interview Survey

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Supplements (adult family member)	Form	Unchanged	Available
Child / Teen Record Check (medical provider)	Form	Unchanged	Available
Screener Questionnaire	Form	Unchanged	Available
Reinterview Survey	Form	Unchanged	Available
Native Hawaiian / Pacific Islander Survey (adult family member)	Form	Unchanged	Repair queued
NHCIS Multi-mode Study (adult family member)	Form	Unchanged	Repair queued
OMB req to increase NHPI screeners 7-22-14.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2014-07-29	Available
NHIS_2014-2016_Supporting Statement_B_12-1-13.doc	Supporting Statement B	Uploaded 2013-12-19	Available
Attachment 7b NHCIS Letters.pdf	Supplementary Document	Uploaded 2013-12-19	Repair queued
Attachment 7a - Flowchart.pdf	Supplementary Document	Uploaded 2013-12-19	Available
Attachment 7 Incentive Experimentation.doc	Supplementary Document	Uploaded 2013-12-19	Available
Attachment 6 - Incentive Experimentation.pdf	Supplementary Document	Uploaded 2013-12-19	Available
Attachment 5c - Research Ethics Review Board Approval.pdf	Supplementary Document	Uploaded 2013-12-19	Available
Attachment 5a - Advance Letters.pdf	Supplementary Document	Uploaded 2013-12-19	Repair queued
Attachment 4a Consultants for 1997 Redesign.pdf	Supplementary Document	Uploaded 2013-12-19	Available
Attachment 3h - Flashcard Booklet.pdf	Supplementary Document	Uploaded 2013-12-19	Repair queued
Attachment 2 - 60 day FR Notice for 2014-6 NHIS rev.pdf	Supplementary Document	Uploaded 2013-12-19	Available
Attachment 1 Legislative Mandate.pdf	Supplementary Document	Uploaded 2013-12-19	Available
NHIS_2014-2016_Supporting Atatement A 12-18-13.doc	Supporting Statement A	Uploaded 2013-12-19	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
45691	Supplements (adult family member)	Form	Unchanged
45690	Child / Teen Record Check (medical provider)	Form	Unchanged
45689	Child Core (adult family member)	Other-Questionaire	Unchanged
45688	Adult Core (sample adult)	Other-Questionaire	Unchanged
45687	Family Core (adult family member)	Other-Questionaire	Unchanged
37725	Screener Questionnaire	Form	Unchanged
205038	Reinterview Survey	Form	Unchanged
186085	Native Hawaiian / Pacific Islander Survey (adult family member)	Form	Unchanged
186084	NHCIS Multi-mode Study (adult family member)	Form	Unchanged

ICR Details

OMB Control No: 0920-0214	ICR Reference No: 201407-0920-017
Status: Historical Active	Previous ICR Reference No: 201312-0920-006
Agency/Subagency: HHS/CDC	Agency Tracking No: 21178
Title: National Health Interview Survey
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 08/07/2014
	Date Received in OIRA: 07/31/2014
Terms of Clearance: CDC/NCHS may use the non-substantive change mechanism to modify existing questions, including those designed to add depth/additional detail and cycle in and out supplemental modules that have been used in the past years (with modest updates). A non-substantive change request is required before fielding the proposed incentive experiment. If new supplemental modules, new questionnaire instruments, or modifications to the sample are anticipated, a full revision of the ICR package must be submitted to OMB.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2016	12/31/2016	12/31/2016
Responses	179,000	0	179,000
Time Burden (Hours)	45,500	0	45,500
Cost Burden (Dollars)	0	0	0

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Abstract: The National Center for Health Statistics (NCHS), Division of Health Interview Statistics is conducting the National Health Interview Survey (OMB #0920-0214 exp. 12/31/16) on a sample of addresses from the 2012 American Community Survey (ACS) where a household member was identified as Native Hawaiian or Pacific Islander (NHPI) alone or in combination with one or more other races (the NHPI NHIS). This request is to increase the number of ACS addresses used in the NHPI NHIS sample.

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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:
	78 FR 59036	09/25/2013
30-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 75920	12/13/2013
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 9

table that charts list of burden

IC Title	Form No.	Form Name
Screener Questionnaire	none	Screener
Family Core (adult family member)
Adult Core (sample adult)
Child Core (adult family member)
Child / Teen Record Check (medical provider)	none	Child/Teen
Supplements (adult family member)	none	Supplements
NHCIS Multi-mode Study (adult family member)	none	NHCIS
Native Hawaiian / Pacific Islander Survey (adult family member)	none	Native Hawaiian Pacific Islander
Reinterview Survey	none	Reinterview

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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	179,000	179,000	0	0	0	0
Annual Time Burden (Hours)	45,500	45,500	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: This revision results in a burden decrease due to reduced screening efforts.

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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: 07/31/2014

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