NCHS Questionnaire Design Research Laboratory

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 0920-0222 Telephone Screener	Form and Instruction	New	Available
Form 0920-0222 Opioid Questionnaire - Card Sort	Form and Instruction	New	Available
Spanish Respondent Data Collection Sheet	Form and Instruction	New	Available
Spanish Questions to be cognitively tested	Form and Instruction	New	Available
Sample screening script for respondent contact Cognitive interviewing study of opioid use and pain questions	Form and Instruction	New	Available
Form 0920-0222 Residential Care Community (RCC) Telephone Screening Script	Form and Instruction	New	Available
Form 0920-0222 Adult Day Care Services Center (ADSC) Telephone Screening Script	Form and Instruction	New	Available
Form 0920-0222 National Study of Long-Term Care Providers 2016 Residential Care Community Questionnaire	Form and Instruction	New	Available
Form 0920-0222 National Study of Long-Term Care Provider 2016 Adult Day Services Center Questionnaire	Form and Instruction	New	Available
Respondent Data Collection Sheet (completed during the cognitive interview)	Form	New	Available
Telephone Screener for Individuals Recruited through the Newspaper Ad	Form and Instruction	New	Available
Questionnaire for Cognitive Testing of Opioid Questions	Form and Instruction	New	Available
Questionnaire - Injury Questions to Evaluate	Form and Instruction	New	Available
Telephone Screener	Form and Instruction	New	Available
Respondent Data Sheet	Form	New	Available
National Survey of Hospital-based Victim Services	Form	New	Available
Teen Alcohol and Marijuana Use Questions to be Cognitively Tested	Form and Instruction	New	Available
Telephone Screening Script- Cognitive Testing of Questions on Teen Alcohol and Marijuana Use	Form and Instruction	New	Available
Form 0920-17AUC Attach 3 Telephone Screener vcb 051017kw no confid pld update	Form and Instruction	New	Available
Form 092017AUC Attach 3 Telephone Screener vcb 051017kw no confid pld update	Form and Instruction	New	Available
Form 0920-0222 Imp Driving - Attach 5 Resp Data Collection Sheet	Form and Instruction	New	Available
Form 0920-0222 Imp Driving - Attach 3 Screener rev-kw	Form and Instruction	New	Available
Respondent data collection sheet	Form	New	Available
Telephone screening script	Form	New	Available
Questions to be cognitively tested	Form	New	Available
Form 1 Questionnaire	Form and Instruction	New	Available
Spanish Data Collection Sheet	Form	New	Available
Spanish Telephone Screener	Form and Instruction	New	Available
Spanish Questions - TBI	Form	New	Available
Cognitive Interview Moderator Guide	Form and Instruction	New	Available
Focus Group Moderator Guide	Form and Instruction	New	Available
Cognitive Interview Screener	Form and Instruction	New	Available
Focus Group Screener	Form and Instruction	New	Available
Respondent data collection sheet	Form	New	Available
Questions to be Cognitively Tested	Form and Instruction	New	Available
Telephone Screening Script for Adult/Self-Responder or Adult Proxy for Child 5-17	Form and Instruction	New	Available
Form 0920-16AEE CQDER CMS Att 1ab Qnne wshowcards	Form and Instruction	New	Available
Form 0920-16AEE CQDER CMS Att 5ab Resp Data Collect	Form and Instruction	New	Available
Form 0920-16AEE CQDER CMS Att 3ab Telephone Screener	Form and Instruction	New	Available
Demographic Sheet	Form	New	Available
Interview Questionnaire	Form	New	Available
Screener	Form	New	Available
Telephone Screening Script	Form and Instruction	New	Available
NHIS Cognitive Functioning and other questions to be cognitively tested	Form and Instruction	New	Available
PRAMS screener	Form	New	Available
PRAMS Phase 8 Supplemental Questions	Form	New	Available
Form 0920-0222 Appendix 5 Resp Data Collection Sheet Spanish NHANES	Form and Instruction	New	Available
Form 0920-0222 Appendix 3 Telephone Screener Spanish NHANES 100215	Form and Instruction	New	Available
Form 0920-0222 Appendix 2a&b Ad&Flyer Spanish NHANES	Form and Instruction	New	Available
Form 0920-0222 Appendix 1 Questionnaire Spanish NHANES 100215	Form and Instruction	New	Available
Respondent Data Sheet	Form	New	Available
Screener	Form and Instruction	New	Available
PRAMS Phase 8 - Spanish	Form	New	Available
Form 0920-0222 (16AG) Appendix 5 - Special Consent	Form and Instruction	New	Available
Form 0920-0222 (16AG) Appendix 4 - NHANES Informed Consent	Form and Instruction	New	Available
Form 0920-0222 (16AG) Appendix 2a&b - NHANES Adv Flyer	Form and Instruction	New	Available
Form 0920-0222 (16AG) Appendix 1 - NHANES Questions for Cognitive Testing	Form and Instruction	New	Available
Form 0920-0222 (16AG) Appendix 3 - NHANES Screener 090215	Form and Instruction	New	Available
Respondent Demographic Data	Form	New	Available
Web Intro Screen	Form	New	Available
Interview Questionnaire	Form	New	Available
Telephone Screener	Form	New	Available
Att O Explain cog interview.doc	Supplementary Document	Uploaded 2015-06-11	Available
Att N Resp data collect sheet.doc	Supplementary Document	Uploaded 2015-06-11	Available
Att M Sample advance letter.doc	Supplementary Document	Uploaded 2015-06-11	Available
Att L QDRL Voice mail script.doc	Supplementary Document	Uploaded 2015-06-11	Available
Att K Sample newspaper adv.doc	Supplementary Document	Uploaded 2015-06-11	Available
Att J Sample flyer.doc	Supplementary Document	Uploaded 2015-06-11	Available
Att I IRB approval.rtf	Supplementary Document	Uploaded 2015-06-11	Available
Att H Spec consent for fg.docx	Supplementary Document	Uploaded 2015-06-11	Available
Att G Spec consent 4offsite research.doc	Supplementary Document	Uploaded 2015-06-11	Available
Supp Statement A 060815.docx	Supporting Statement A	Uploaded 2015-06-11	Available
Att F Spec consent.docx	Supplementary Document	Uploaded 2015-06-11	Available
Att E informed consent.doc	Supplementary Document	Uploaded 2015-06-11	Available
Att D screening script.doc	Supplementary Document	Uploaded 2015-06-11	Available
Att C nondisclosure affidavit.doc	Supplementary Document	Uploaded 2015-06-11	Available
Attach B 60day Fed Reg Notice.pdf	Supplementary Document	Uploaded 2015-06-11	Available
Att A Pub Health Serv Act.doc	Supplementary Document	Uploaded 2015-06-11	Available
Supp Statement B 052815.doc	Supporting Statement B	Uploaded 2015-06-11	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
231689	CQDER - Opioid Plus Card Sort	Form and Instruction	New	Telephone Screener
231689	CQDER - Opioid Plus Card Sort	Form and Instruction	New	Opioid Questionnaire - Card Sort
231500	Cognitive Interviewing Study of Opioid-Related Questions (Spanish Version)	Form and Instruction	New	Spanish Respondent Data Collection Sheet
231500	Cognitive Interviewing Study of Opioid-Related Questions (Spanish Version)	Form and Instruction	New	Spanish Questions to be cognitively tested
231500	Cognitive Interviewing Study of Opioid-Related Questions (Spanish Version)	Form and Instruction	New	Sample screening script for respondent contact Cognitive interviewing study of opioid use and pain questions
231481	Collaborating Center for Questionnaire Design and Evaluation Research (CCQDER)	Form and Instruction	New	Residential Care Community (RCC) Telephone Screening Script
231481	Collaborating Center for Questionnaire Design and Evaluation Research (CCQDER)	Form and Instruction	New	Adult Day Care Services Center (ADSC) Telephone Screening Script
231481	Collaborating Center for Questionnaire Design and Evaluation Research (CCQDER)	Form and Instruction	New	National Study of Long-Term Care Providers 2016 Residential Care Community Questionnaire
231481	Collaborating Center for Questionnaire Design and Evaluation Research (CCQDER)	Form and Instruction	New	National Study of Long-Term Care Provider 2016 Adult Day Services Center Questionnaire
231306	Cognitive Interviewing Study of Opioid-Related Questions	Form	New	Respondent Data Collection Sheet (completed during the cognitive interview)
231306	Cognitive Interviewing Study of Opioid-Related Questions	Form and Instruction	New	Telephone Screener for Individuals Recruited through the Newspaper Ad
231306	Cognitive Interviewing Study of Opioid-Related Questions	Form and Instruction	New	Questionnaire for Cognitive Testing of Opioid Questions
230189	NHANES Contact and Message Testing	Other-ord	New
229901	Research and Development Survey (RANDS) Cognitive Interviewing Sub-Study	Other-WORD	New
229527	Cognitive Testing of ASPE Criminal Justice System Questions	Other-WORD	New
229163	Cognitve Testing of Food for Babies and Mothers' Health Question on the NHANES B24 Month Questionnaire	Other-WORD	New
228813	Questionnaire Design and Evaluation Research on Injury for the National Health Interview Survey (NHIS)	Form and Instruction	New	Questionnaire - Injury Questions to Evaluate
228813	Questionnaire Design and Evaluation Research on Injury for the National Health Interview Survey (NHIS)	Form and Instruction	New	Telephone Screener
228398	Cognitive Testing of National Survey of Hospital-Based Victim Services (NSHVS)	Form	New	Respondent Data Sheet
228398	Cognitive Testing of National Survey of Hospital-Based Victim Services (NSHVS)	Form	New	National Survey of Hospital-based Victim Services
228398	Cognitive Testing of National Survey of Hospital-Based Victim Services (NSHVS)	Other-Telephone script	New
228379	Cognitive Testing of Questions on Teen Alcohol and Marijuana Use	Form and Instruction	New	Teen Alcohol and Marijuana Use Questions to be Cognitively Tested
228379	Cognitive Testing of Questions on Teen Alcohol and Marijuana Use	Form and Instruction	New	Telephone Screening Script- Cognitive Testing of Questions on Teen Alcohol and Marijuana Use
227302	Cognitive Testing of NHIS health care utilization smoking, and selected child questions	Form and Instruction	New	Attach 3 Telephone Screener vcb 051017kw no confid pld update
227302	Cognitive Testing of NHIS health care utilization smoking, and selected child questions	Form and Instruction	New	Attach 3 Telephone Screener vcb 051017kw no confid pld update
226479	Cognitive Testing of Impaired Driving Questions for CDC National Center for Injury Prevention and Control (NPIPC)	Form and Instruction	New	Imp Driving - Attach 5 Resp Data Collection Sheet
226479	Cognitive Testing of Impaired Driving Questions for CDC National Center for Injury Prevention and Control (NPIPC)	Form and Instruction	New	Imp Driving - Attach 3 Screener rev-kw
224421	Cognitive Testing of Middle Eastern North African (MENA) Questions	Form	New	Respondent data collection sheet
224421	Cognitive Testing of Middle Eastern North African (MENA) Questions	Form	New	Telephone screening script
224421	Cognitive Testing of Middle Eastern North African (MENA) Questions	Form	New	Questions to be cognitively tested
223727	Cognitive testing of Confidentiality Pledge, Round 2	Other-WORD	New
223623	Labor Force Module of Persons with Disabilities Round 2	Form and Instruction	New	Questionnaire
223623	Labor Force Module of Persons with Disabilities Round 2	Other-WORD	New
223018	Spanish Cognitive Study to Examine Traumatic Brain Injury Questions	Form	New	Spanish Data Collection Sheet
223018	Spanish Cognitive Study to Examine Traumatic Brain Injury Questions	Form and Instruction	New	Spanish Telephone Screener
223018	Spanish Cognitive Study to Examine Traumatic Brain Injury Questions	Form	New	Spanish Questions - TBI
222327	Trust, Acceptance and Confidence in Vaccines and Vaccination Schedules	Form and Instruction	New	Cognitive Interview Moderator Guide
222327	Trust, Acceptance and Confidence in Vaccines and Vaccination Schedules	Form and Instruction	New	Focus Group Moderator Guide
222327	Trust, Acceptance and Confidence in Vaccines and Vaccination Schedules	Form and Instruction	New	Cognitive Interview Screener
222327	Trust, Acceptance and Confidence in Vaccines and Vaccination Schedules	Form and Instruction	New	Focus Group Screener
221825	Congitive Testing of Confidentiality Pledges	Form	New	Respondent data collection sheet
221825	Congitive Testing of Confidentiality Pledges	Other-Testing Materials	New
221813	Evaluation of Traumatic Brain Injury Questions for CDC's National Center for Injury Prevention and Control (NCIPC)	Form and Instruction	New	Questions to be Cognitively Tested
221813	Evaluation of Traumatic Brain Injury Questions for CDC's National Center for Injury Prevention and Control (NCIPC)	Form and Instruction	New	Telephone Screening Script for Adult/Self-Responder or Adult Proxy for Child 5-17
221510	2017 NHANES Health Behaviors Cognitive Interviewing Study	Other-WORD	New
221257	Center for Questionnaire Design and Evaluation Research (CQDER) CMS 10-day Letter	Form and Instruction	New	CQDER CMS Att 1ab Qnne wshowcards
221257	Center for Questionnaire Design and Evaluation Research (CQDER) CMS 10-day Letter	Form and Instruction	New	CQDER CMS Att 5ab Resp Data Collect
221257	Center for Questionnaire Design and Evaluation Research (CQDER) CMS 10-day Letter	Form and Instruction	New	CQDER CMS Att 3ab Telephone Screener
221257	Center for Questionnaire Design and Evaluation Research (CQDER) CMS 10-day Letter	Instruction	New
221137	2016 CDC Healthcare Systems Scorecard (HSSC) Assessment Tool for Primary Care Practices	Form	New	Demographic Sheet
221137	2016 CDC Healthcare Systems Scorecard (HSSC) Assessment Tool for Primary Care Practices	Form	New	Interview Questionnaire
221137	2016 CDC Healthcare Systems Scorecard (HSSC) Assessment Tool for Primary Care Practices	Form	New	Screener
220340	Testing of questions on cognitive functioning and other questions for the National Health Interview Survey (NHIS)	Form and Instruction	New	Telephone Screening Script
220340	Testing of questions on cognitive functioning and other questions for the National Health Interview Survey (NHIS)	Form and Instruction	New	NHIS Cognitive Functioning and other questions to be cognitively tested
220016	GenIC UNICEF/Washington Group School Environment Evaluation Study 2016	Other-WORD	New
219197	PRAMS - English	Form	New	PRAMS screener
219197	PRAMS - English	Form	New	PRAMS Phase 8 Supplemental Questions
219178	Labor Force Module of Persons with Disabilities	Other-Telephone Screener	New
218756	2017 NHANES Health Behaviors Cognitive Interviewing Study/Spanish	Form and Instruction	New	Appendix 5 Resp Data Collection Sheet Spanish NHANES
218756	2017 NHANES Health Behaviors Cognitive Interviewing Study/Spanish	Form and Instruction	New	Appendix 3 Telephone Screener Spanish NHANES 100215
218756	2017 NHANES Health Behaviors Cognitive Interviewing Study/Spanish	Form and Instruction	New	Appendix 2a&b Ad&Flyer Spanish NHANES
218756	2017 NHANES Health Behaviors Cognitive Interviewing Study/Spanish	Form and Instruction	New	Appendix 1 Questionnaire Spanish NHANES 100215
218756	2017 NHANES Health Behaviors Cognitive Interviewing Study/Spanish	Instruction	New
218569	PRAMS Phase 8 - Spanish	Form	New	Respondent Data Sheet
218569	PRAMS Phase 8 - Spanish	Form and Instruction	New	Screener
218569	PRAMS Phase 8 - Spanish	Form	New	PRAMS Phase 8 - Spanish
218517	2017 NHANES Health Behaviors Cognitive Interviewing Study	Form and Instruction	New	Appendix 5 - Special Consent
218517	2017 NHANES Health Behaviors Cognitive Interviewing Study	Form and Instruction	New	Appendix 4 - NHANES Informed Consent
218517	2017 NHANES Health Behaviors Cognitive Interviewing Study	Form and Instruction	New	Appendix 2a&b - NHANES Adv Flyer
218517	2017 NHANES Health Behaviors Cognitive Interviewing Study	Form and Instruction	New	Appendix 1 - NHANES Questions for Cognitive Testing
218517	2017 NHANES Health Behaviors Cognitive Interviewing Study	Form and Instruction	New	Appendix 3 - NHANES Screener 090215
218109	RANDS	Form	New	Respondent Demographic Data
218109	RANDS	Form	New	Web Intro Screen
218109	RANDS	Form	New	Interview Questionnaire
218109	RANDS	Form	New	Telephone Screener

ICR Details

OMB Control No: 0920-0222	ICR Reference No: 201506-0920-003
Status: Historical Active	Previous ICR Reference No: 201205-0920-001
Agency/Subagency: HHS/CDC	Agency Tracking No:
Title: NCHS Questionnaire Design Research Laboratory
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: 07/21/2015
Retrieve Notice of Action (NOA)	Date Received in OIRA: 06/19/2015
Terms of Clearance: CDC will continue to submit individual collections under this generic clearance to OMB. OMB will strive to provide feedback on the individual collections within ten working days, whenever possible, as is currently the case. Standard remuneration of respondents for cognitive testing is $40.00. Higher remunerations may be requested with justification for difficult recruitments, focus groups, etc.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2018	36 Months From Approved	07/31/2015
Responses	24,000	0	9,300
Time Burden (Hours)	13,150	0	9,450
Cost Burden (Dollars)	0	0	0

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Abstract: The revision requested consists of an increase in burden hours for the next 3-year approval period. The purpose and use of collecting this information fall into five categories: 1) Development and testing of specific survey questionnaires; 2) Research on the cognitive and interpretive aspects of survey methodology; 3) Research on human-computer interfaces/usability; 4) Field tests/Pilot interviewing; and 5) Studies of the optimal design and presentation of statistical graphical and textual material. Methods for data collection include interviewer administered, self-administered, telephone, Computer Assisted Personal Interviewing (CAPI) and Computer Assisted Self-Interviewing (CASI), Audio Computer-Assisted Self-Interviewing (ACASI), and web-based questionnaires including: cognitive interviewing, focus groups, usability testing, and field tests/pilot household interviews.

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Authorizing Statute(s): US Code: 42 USC 242k 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:
	80 FR 13868	03/17/2015
30-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 34644	06/17/2015
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 31

table that charts list of burden

IC Title	Form No.	Form Name
2016 CDC Healthcare Systems Scorecard (HSSC) Assessment Tool for Primary Care Practices	none, none, none	Screener ,   Interview Questionnaire ,   Demographic Sheet
2017 NHANES Health Behaviors Cognitive Interviewing Study	0920-0222 (16AG), 0920-0222 (16AG), 0920-0222 (16AG) , 0920-0222 (16AG), 0920-0222 (16AG)	Appendix 3 - NHANES Screener 090215 ,   Appendix 1 - NHANES Questions for Cognitive Testing ,   Appendix 2a&b - NHANES Adv Flyer ,   Appendix 4 - NHANES Informed Consent ,   Appendix 5 - Special Consent
2017 NHANES Health Behaviors Cognitive Interviewing Study
2017 NHANES Health Behaviors Cognitive Interviewing Study/Spanish	0920-0222, 0920-0222, 0920-0222, 0920-0222	Appendix 1 Questionnaire Spanish NHANES 100215 ,   Appendix 2a&b Ad&Flyer Spanish NHANES ,   Appendix 3 Telephone Screener Spanish NHANES 100215 ,   Appendix 5 Resp Data Collection Sheet Spanish NHANES
CQDER - Opioid Plus Card Sort	0920-0222, 0920-0222	Opioid Questionnaire - Card Sort ,   Telephone Screener
Center for Questionnaire Design and Evaluation Research (CQDER) CMS 10-day Letter	0920-16AEE, 0920-16AEE, 0920-16AEE	CQDER CMS Att 3ab Telephone Screener ,   CQDER CMS Att 5ab Resp Data Collect ,   CQDER CMS Att 1ab Qnne wshowcards
Cognitive Interviewing Study of Opioid-Related Questions	n/a, n/a, n/a	Questionnaire for Cognitive Testing of Opioid Questions ,   Telephone Screener for Individuals Recruited through the Newspaper Ad ,   Respondent Data Collection Sheet (completed during the cognitive interview)
Cognitive Interviewing Study of Opioid-Related Questions (Spanish Version)	n/a, n/a, n/a	Sample screening script for respondent contact Cognitive interviewing study of opioid use and pain questions ,   Spanish Questions to be cognitively tested ,   Spanish Respondent Data Collection Sheet
Cognitive Testing of ASPE Criminal Justice System Questions
Cognitive Testing of Impaired Driving Questions for CDC National Center for Injury Prevention and Control (NPIPC)	0920-0222, 0920-0222	Imp Driving - Attach 3 Screener rev-kw ,   Imp Driving - Attach 5 Resp Data Collection Sheet
Cognitive Testing of Middle Eastern North African (MENA) Questions	None, None, None	Questions to be cognitively tested ,   Telephone screening script ,   Respondent data collection sheet
Cognitive Testing of NHIS health care utilization smoking, and selected child questions	092017AUC, 0920-17AUC	Attach 3 Telephone Screener vcb 051017kw no confid pld update ,   Attach 3 Telephone Screener vcb 051017kw no confid pld update
Cognitive Testing of National Survey of Hospital-Based Victim Services (NSHVS)	none, none	National Survey of Hospital-based Victim Services ,   Respondent Data Sheet
Cognitive Testing of Questions on Teen Alcohol and Marijuana Use	NA, NA	Telephone Screening Script- Cognitive Testing of Questions on Teen Alcohol and Marijuana Use ,   Teen Alcohol and Marijuana Use Questions to be Cognitively Tested
Cognitive testing of Confidentiality Pledge, Round 2
Cognitve Testing of Food for Babies and Mothers' Health Question on the NHANES B24 Month Questionnaire
Collaborating Center for Questionnaire Design and Evaluation Research (CCQDER)	0920-0222, 0920-0222, 0920-0222, 0920-0222	National Study of Long-Term Care Provider 2016 Adult Day Services Center Questionnaire ,   National Study of Long-Term Care Providers 2016 Residential Care Community Questionnaire ,   Adult Day Care Services Center (ADSC) Telephone Screening Script ,   Residential Care Community (RCC) Telephone Screening Script
Congitive Testing of Confidentiality Pledges	none	Respondent data collection sheet
Evaluation of Traumatic Brain Injury Questions for CDC's National Center for Injury Prevention and Control (NCIPC)	NA, NA	Telephone Screening Script for Adult/Self-Responder or Adult Proxy for Child 5-17 ,   Questions to be Cognitively Tested
GenIC UNICEF/Washington Group School Environment Evaluation Study 2016
Labor Force Module of Persons with Disabilities
Labor Force Module of Persons with Disabilities Round 2	1	Questionnaire
NHANES Contact and Message Testing
PRAMS - English	none, none	PRAMS Phase 8 Supplemental Questions ,   PRAMS screener
PRAMS Phase 8 - Spanish	none, none, none	PRAMS Phase 8 - Spanish ,   Screener ,   Respondent Data Sheet
Questionnaire Design and Evaluation Research on Injury for the National Health Interview Survey (NHIS)	NA, NA	Telephone Screener ,   Questionnaire - Injury Questions to Evaluate
RANDS	none, none, none, none	Telephone Screener ,   Interview Questionnaire ,   Web Intro Screen ,   Respondent Demographic Data
Research and Development Survey (RANDS) Cognitive Interviewing Sub-Study
Spanish Cognitive Study to Examine Traumatic Brain Injury Questions	none, none, none	Spanish Questions - TBI ,   Spanish Telephone Screener ,   Spanish Data Collection Sheet
Testing of questions on cognitive functioning and other questions for the National Health Interview Survey (NHIS)	NA, NA	NHIS Cognitive Functioning and other questions to be cognitively tested ,   Telephone Screening Script
Trust, Acceptance and Confidence in Vaccines and Vaccination Schedules	NA, NA, NA, NA	Focus Group Screener ,   Cognitive Interview Screener ,   Focus Group Moderator Guide ,   Cognitive Interview Moderator Guide

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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	24,000	9,300	0	14,700	0	0
Annual Time Burden (Hours)	13,150	9,450	0	3,700	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: No

Burden Reduction Due to:

Short Statement: CDC is requesting an increase in burden hours and respondents due to anticipated increase in the number and size of projects planned during the next 3 years.

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Annual Cost to Federal Government: $1,801,033

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]? No

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: 06/19/2015

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