Information Collection

2017 NHANES Health Behaviors Cognitive Interviewing Study

IC 218517 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⚠️ Notice: This information collection may be referencing outdated material.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
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

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:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.