National Health Interview Survey

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Supplements (adult family member)	Form	Removed	Available
Child / Teen Record Check (medical provider)	Form	Removed	Available
Screener Questionnaire	Form	Removed	Repair queued
Followback Survey Questionnaire	Form and Instruction	New	Available
Reinterview Survey	Form and Instruction	New	Available
New Supplements and Core Changes	Form and Instruction	New	Repair queued
Sample Child Core Questionnaire	Form and Instruction	New	Repair queued
Sample Adult Core Questionnaire	Form and Instruction	New	Available
Family Core Questionnaire	Form and Instruction	New	Repair queued
OMB Statement and Screener	Form and Instruction	New	Available
Reinterview Survey	Form	Removed	Repair queued
Native Hawaiian / Pacific Islander Survey (adult family member)	Form	Removed	Available
NHCIS Multi-mode Study (adult family member)	Form	Removed	Repair queued
Attachment 5b - ERB Approval.pdf	Supplementary Document	Uploaded 2014-12-04	Repair queued
Attachment 5a - Advance Letters.pdf	Supplementary Document	Uploaded 2014-12-04	Available
Attachment 4 - Consultants for 1997 Redesign.pdf	Supplementary Document	Uploaded 2014-12-04	Repair queued
Attachment 3j - Core and Supplement Changes Summary Table.pdf	Supplementary Document	Uploaded 2014-12-04	Repair queued
Attachment 3i - 2015 NHIS Removal of Health Care Reform Questions.pdf	Supplementary Document	Uploaded 2014-12-04	Available
Attachment 3h - 2015 Followback Survey Description.pdf	Supplementary Document	Uploaded 2014-12-04	Available
Attachment 3e - 2015 NHIS Flashcards.pdf	Supplementary Document	Uploaded 2014-12-04	Available
Attachment 2b - 60-Day FRN Public Comments and Response.pdf	Supplementary Document	Uploaded 2014-12-04	Available
Attachment 2a - 60-day FRN.pdf	Supplementary Document	Uploaded 2014-12-04	Repair queued
Attachment 1 - Legislative Mandates.pdf	Supplementary Document	Uploaded 2014-12-04	Repair queued
2015 NHIS_2015-2017_SS_B 122314.doc	Supporting Statement B	Uploaded 2014-12-27	Available
2015 NHIS_2014-2016_SS_A 122314.doc	Supporting Statement A	Uploaded 2014-12-27	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
45691	Supplements (adult family member)	Form	Removed
45690	Child / Teen Record Check (medical provider)	Form	Removed
45689	Child Core (adult family member)	Other-Questionaire	Removed
45688	Adult Core (sample adult)	Other-Questionaire	Removed
45687	Family Core (adult family member)	Other-Questionaire	Removed
37725	Screener Questionnaire	Form	Removed
214142	Followback Survey Questionnaire	Form and Instruction	New
214116	Reinterview Survey	Form and Instruction	New
214115	New Supplements and Core Changes	Form and Instruction	New
214114	Sample Child Core Questionnaire	Form and Instruction	New
214113	Sample Adult Core Questionnaire	Form and Instruction	New
214112	Family Core Questionnaire	Form and Instruction	New
214111	OMB Statement and Screener	Form and Instruction	New
205038	Reinterview Survey	Form	Removed
186085	Native Hawaiian / Pacific Islander Survey (adult family member)	Form	Removed
186084	NHCIS Multi-mode Study (adult family member)	Form	Removed

ICR Details

OMB Control No: 0920-0214	ICR Reference No: 201412-0920-004
Status: Historical Active	Previous ICR Reference No: 201407-0920-017
Agency/Subagency: HHS/CDC	Agency Tracking No: 21178
Title: National Health Interview Survey
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 01/01/2015
	Date Received in OIRA: 12/16/2014
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	12/31/2017	36 Months From Approved	12/31/2016
Responses	167,000	0	179,000
Time Burden (Hours)	48,833	0	45,500
Cost Burden (Dollars)	0	0	0

---

Abstract: The NHIS is conducted by the National Center for Health Statistics (NCHS), Centers for Disease Control and Prevention (CDC), to comply with the NCHS mandate under 42 USC 242k to collect, on an annual basis, statistically valid data on the amount, distribution, and effects of illness and disability in the population and on the utilization of health care services for such conditions. NHIS data are used widely throughout the Department of Health and Human Services (DHHS) to monitor trends in illness and disability and to track progress toward achieving many of the Healthy People objectives for the nation. This revision request is to conduct the National Health Interview Survey for 2015-2017; to continue the increase in the previous two year's sample size; to introduce a program to improve response rates using promotional materials, additional interviewer training, and incentives; to conduct a follow-back survey of sample adult respondents from an earlier NHIS; and to modify selected sections of the 2015, 2016, and 2017 surveys through a nonsubstantive change clearance request.

---

Authorizing Statute(s): US Code: 42 USC 242 Name of Law: Public Health Service Act
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 52343	09/03/2014
30-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 71432	12/02/2014
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 7

table that charts list of burden

IC Title	Form No.	Form Name
Reinterview Survey	None	2015 Reinterview Survey
Supplements (adult family member)	none	Supplements
OMB Statement and Screener	None	2015 OMB Statement and Screener
Sample Adult Core Questionnaire	None	2015 Sample Adult Core Questionnaire
Followback Survey Questionnaire	None	2015 FollowBack Survey Questionnaire
Child Core (adult family member)
Child / Teen Record Check (medical provider)	none	Child/Teen
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
Family Core Questionnaire	None	2015 Family Core Questionnaire
Screener Questionnaire	none	Screener
Family Core (adult family member)
Adult Core (sample adult)
Sample Child Core Questionnaire	None	2015 Sample Child Core Questionnaire
New Supplements and Core Changes	None	2015 New Supplements and Core Changes

---

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	167,000	179,000	0	-12,000	0	0
Annual Time Burden (Hours)	48,833	45,500	0	3,333	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: Changes or adjustments in this Revision are the result of modifications to selected sections of the National Health Interview Survey (NHIS)

---

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

---

Common Form ICR:  No

---

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: 12/16/2014

---