Attachment 1a: Questions to be cognitively tested
The Public Health Service Act provides us with the authority to do this research (42 United States Code 242k). All information which would permit identification of any individual, a practice, or an establishment will be held confidential, will be used for statistical purposes only by NCHS staff, contractors, and agents only when required and with necessary controls, and will not be disclosed or released to other persons without the consent of the individual or the establishment in accordance with section 308(d) of the Public Health Service Act (42 USC 242m(d)) and the Confidential Information Protection and Statistical Efficiency Act (PL-107-347).
Public reporting burden for this collection of information is estimated to average 60 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to CDC/ATSDR Information Collection Review Office; 1600 Clifton Road NE, MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0222).
Form Approved OMB #0920-0222; Expiration Date: 07/31/2018
1. Have you ever been arrested? Yes No |
2. [If YES to arrested] How many times have you been arrested for a crime?
___________
|
3. Have you ever been incarcerated (in either jail or prison excluding juvenile detention)? Yes No |
4. [If YES to incarceration] How many times?
___________
|
5. [If YES to incarceration] What is the longest amount of time you spent in jail or prison?
___________
|
6. [If YES to incarceration] What is the total duration of your incarceration experiences?
___________
|
7. [If Yes to incarceration] What is the total number of months you have spent incarcerated?
___________
|
8. [If YES to incarceration] What age were you when you were first in jail or prison?
___________
|
9. [If YES to incarceration] What was the most recent incarceration?
___________
|
Family Level |
11. Has your spouse ever been incarcerated (in either jail or prison excluding juvenile detention)? Yes No |
12. [If YES to incarceration] How many times?
___________times
|
13. [If YES to incarceration] What is total length of time incarcerated?
___________total length of time
|
14. [If YES to incarceration] What is the total number of months your spouse has spent incarcerated?
___________total duration incarcerated
|
15. Is anyone who would otherwise be living in your household currently incarcerated? Yes No |
16. [If YES] What is your relationship to this person? ____________________
|
17. Has any member of your immediate or extended family spent time in jail or prison – not including when they were in juvenile detention? Yes No |
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Whitaker, Karen R. (CDC/OPHSS/NCHS) |
| File Modified | 0000-00-00 |
| File Created | 2021-01-21 |