Information Collection

DSM-5 Cognitive Interviews

IC 214267 under ICR 201407-0930-001 · OMB 0930-0290.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0930-0290 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Survey Instrument DSM-5 Cognitive Interviews	Form and Instruction
Survey Instrument Survey Instrument Attachment I_SurveyInstrument_FINAL.docx	Form and Instruction
Attachment A_Recruitment_Flyers_FINAL.docx Recruitment Flyers	IC Document
Attachment B_Web Recruitment Screener_FINAL.docx Web Recruitment Screener	IC Document
Attachment C_Telephone Recruitment Screener_FINAL.docx Telephone Recruitment Screener	IC Document
Attachment D_Parental Permission Form_FINAL.docx Parental Permission Form	IC Document
Attachment E_Participant Informed Consent Form_FINAL.docx Participant Informed Consent Form	IC Document
Attachment F_CogTesting_Protocol_FINAL.docx CogTesting_Protocol	IC Document
Attachment G_Receipt for Participation_FINAL.docx Receipt for Participation	IC Document
Attachment H_Federalwide Assurance_FINAL.pdf Federalwide Assurance	IC Document
DSM Pretest_OMB SS_12.16.14.docx Supporting Statement	IC Document

IC Title:

DSM-5 Cognitive Interviews

Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	Survey Instrument	Survey Instrument	Attachment I_SurveyInstrument_FINAL.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 150

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	150	150
Annual IC Time Burden (Hours)	64	64
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Recruitment Flyers	Attachment A_Recruitment_Flyers_FINAL.docx	12/16/2014
Web Recruitment Screener	Attachment B_Web Recruitment Screener_FINAL.docx	12/16/2014
Telephone Recruitment Screener	Attachment C_Telephone Recruitment Screener_FINAL.docx	12/16/2014
Parental Permission Form	Attachment D_Parental Permission Form_FINAL.docx	12/16/2014
Participant Informed Consent Form	Attachment E_Participant Informed Consent Form_FINAL.docx	12/16/2014
CogTesting_Protocol	Attachment F_CogTesting_Protocol_FINAL.docx	12/16/2014
Receipt for Participation	Attachment G_Receipt for Participation_FINAL.docx	12/16/2014
Federalwide Assurance	Attachment H_Federalwide Assurance_FINAL.pdf	12/16/2014
Supporting Statement	DSM Pretest_OMB SS_12.16.14.docx	12/16/2014

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