Information Collection

DSM-5 Cognitive Interviews

IC 214267 under ICR 201502-0930-001 · 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⚠️ Notice: This information collection may be referencing outdated material.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 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

IC Title:

DSM-5 Cognitive Interviews

Agency IC Tracking Number:

IC Status: Modified

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				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
	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

table that charts IC Documents
Title	Document	Date Uploaded
CogTesting_Protocol		12/16/2014
Receipt for Participation		12/16/2014
Federalwide Assurance		12/16/2014
Recruitment_Flyers		02/23/2015
Web Recruitment Screener		02/23/2015
Telephone Recruitment Screener		02/23/2015
Parental Permission Form		02/23/2015
Participant Informed Consent Form		02/23/2015
Distressed Respondent Protocol		02/23/2015
Supporting Statement		02/23/2015

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

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