Information Collection

Rands

IC 218109 under ICR 201506-0920-003 · OMB 0920-0222.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0222 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
RANDS	Form
Telephone Screener Appendix 3ab - Telephone Screeners-final.docx	Form
Interview Questionnaire Appendix 1 - Interviewer Administered Questionnaire rev.docx	Form
Web Intro Screen Appendix 6 - Web Introduction Screen.docx	Form
Respondent Demographic Data Demographic Info.doc	Form
Appendix 7 - Gallup Data Protection and Security Overview 2015.pdf Gallup Data Protection	IC Document
Appendix 4 - Informed Consent-final.docx Informed Consent	IC Document
Appendix 2 - Cog Int Adv&flyer.docx Ad/Flyier	IC Document
OMB 10 Day Letter_RAND_0826 2015.docx Supporting Statement	IC Document
Appendix 5 - Special Consent rev2.docx Special Consent	IC Document

IC Title:

RANDS

Agency IC Tracking Number:

15BFA

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	none	Telephone Screener	Appendix 3ab - Telephone Screeners-final.docx	Yes	Yes	Fillable Fileable
Form	none	Interview Questionnaire	Appendix 1 - Interviewer Administered Questionnaire rev.docx	No		Paper Only
Form	none	Web Intro Screen	Appendix 6 - Web Introduction Screen.docx	Yes	Yes	Fillable Fileable
Form	none	Respondent Demographic Data	Demographic Info.doc	No		Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: 09-20-0164 Health and Demographic Surveys Conducted in Probability Samples of the U.S. Population

FR Citation: 49 FR 37693

Number of Respondents: 4,132

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 60 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	4,132	4,132
Annual IC Time Burden (Hours)	1,399	1,399
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Gallup Data Protection	Appendix 7 - Gallup Data Protection and Security Overview 2015.pdf	09/08/2015
Informed Consent	Appendix 4 - Informed Consent-final.docx	09/08/2015
Ad/Flyier	Appendix 2 - Cog Int Adv&flyer.docx	09/08/2015
Supporting Statement	OMB 10 Day Letter_RAND_0826 2015.docx	09/08/2015
Special Consent	Appendix 5 - Special Consent rev2.docx	09/18/2015

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