2017 NHANES Health Behaviors Cognitive Interviewing Study

NCHS Questionnaire Design Research Laboratory

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Document Name Document Type
Form 0920-0222 (16AG) 2017 NHANES Health Behaviors Cognitive Interviewing Study Form and Instruction
0920-0222 (16AG) Appendix 3 - NHANES Screener 090215 Appendix 3 - NHANES Screener 090215.docx Form and Instruction
0920-0222 (16AG) Appendix 1 - NHANES Questions for Cognitive Testing Appendix 1 - NHANES Questions for Cognitive Testing 090215.docx Form and Instruction
0920-0222 (16AG) Appendix 2a&b - NHANES Adv Flyer Appendix 2a&b - NHANES Adv Flyer.docx Form and Instruction
0920-0222 (16AG) Appendix 4 - NHANES Informed Consent Appendix 4 - NHANES Informed Consent 090215.docx Form and Instruction
0920-0222 (16AG) Appendix 5 - Special Consent Appendix 5 - Special Consent rev2.docx Form and Instruction
10-day NHANES letter 100215.docx 10-day NHANES letter IC Document
flashcard ALQ1.pdf flashcard ALQ1 IC Document

Information Collection (IC) Details

IC Title:	2017 NHANES Health Behaviors Cognitive Interviewing Study	Agency IC Tracking Number:	16AG

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	0920-0222 (16AG)	Appendix 3 - NHANES Screener 090215	Appendix 3 - NHANES Screener 090215.docx	Yes	Yes	Fillable Printable
Form and Instruction	0920-0222 (16AG)	Appendix 1 - NHANES Questions for Cognitive Testing	Appendix 1 - NHANES Questions for Cognitive Testing 090215.docx	Yes	Yes	Fillable Printable
Form and Instruction	0920-0222 (16AG)	Appendix 2a&b - NHANES Adv Flyer	Appendix 2a&b - NHANES Adv Flyer.docx	Yes	Yes	Fillable Printable
Form and Instruction	0920-0222 (16AG)	Appendix 4 - NHANES Informed Consent	Appendix 4 - NHANES Informed Consent 090215.docx	Yes	Yes	Fillable Printable
Form and Instruction	0920-0222 (16AG)	Appendix 5 - Special Consent	Appendix 5 - Special Consent rev2.docx	Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title: Health and Demographic Surveys Conducted in Probablity Sampes of the U.S. Population 09-20-0164	FR Citation: 49 FR 37693

Number of Respondents: 156	Number of Respondents for Small Entity: 0

Affected Public: Federal Government

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	156	156
Annual IC Time Burden (Hours)	68	68
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
10-day NHANES letter	10-day NHANES letter 100215.docx	10/07/2015
flashcard ALQ1	flashcard ALQ1.pdf	10/07/2015

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