DSM-5 Cognitive Interviews

National Survey on Drug Use and Health: Methodological Field Tests

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

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 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
Attachment A_Recruitment_Flyers_FINALrev.docx Recruitment_Flyers IC Document
Attachment B_Web Recruitment Screener_FINALrev.docx Web Recruitment Screener IC Document
Attachment C_Telephone Recruitment Screener_FINALrev.docx Telephone Recruitment Screener IC Document
Attachment D_Parental Permission Form_FINALrev.docx Parental Permission Form IC Document
Attachment E_Participant Informed Consent Form_FINALrev.docx Participant Informed Consent Form IC Document
Attachment J_Distressed Respondent Protocol_FINAL.docx Distressed Respondent Protocol IC Document
DSM Pretest_OMB Supporting Statement_FINAL_rev.docx Supporting Statement IC Document

Information Collection (IC) Details

IC Title:	DSM-5 Cognitive Interviews	Agency IC Tracking Number:

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection 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 %

	Requested	Previously Approved
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

Title	Document	Date Uploaded
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
Recruitment_Flyers	Attachment A_Recruitment_Flyers_FINALrev.docx	02/23/2015
Web Recruitment Screener	Attachment B_Web Recruitment Screener_FINALrev.docx	02/23/2015
Telephone Recruitment Screener	Attachment C_Telephone Recruitment Screener_FINALrev.docx	02/23/2015
Parental Permission Form	Attachment D_Parental Permission Form_FINALrev.docx	02/23/2015
Participant Informed Consent Form	Attachment E_Participant Informed Consent Form_FINALrev.docx	02/23/2015
Distressed Respondent Protocol	Attachment J_Distressed Respondent Protocol_FINAL.docx	02/23/2015
Supporting Statement	DSM Pretest_OMB Supporting Statement_FINAL_rev.docx	02/23/2015

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