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2017 NHANES Health Behaviors Cognitive Interviewing Study/Spanish
NCHS Questionnaire Design Research Laboratory
OMB: 0920-0222
IC ID: 218756
OMB.report
HHS/CDC
OMB 0920-0222
ICR 201506-0920-003
IC 218756
( )
⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0222 can be found here:
2022-12-21 - Revision of a currently approved collection
2021-08-16 - Revision of a currently approved collection
Documents and Forms
Document Name
Document Type
Form 0920-0222
2017 NHANES Health Behaviors Cognitive Interviewing Study/Spanish
Form and Instruction
ALQ1 Flashcard Spanish.pdf
Instruction
Appendix 6 Thank You letter Spanish NHANES.docx
Instruction
0920-0222 Appendix 1 Questionnaire Spanish NHANES 100215
Appendix 1 Questionnaire Spanish NHANES 100215.docx
Form and Instruction
0920-0222 Appendix 2a&b Ad&Flyer Spanish NHANES
Appendix 2a&b Ad&Flyer Spanish NHANES.docx
Form and Instruction
0920-0222 Appendix 3 Telephone Screener Spanish NHANES 100215
Appendix 3 Telephone Screener Spanish NHANES 100215.docx
Form and Instruction
0920-0222 Appendix 5 Resp Data Collection Sheet Spanish NHANES
Appendix 5 Resp Data Collection Sheet Spanish NHANES.docx
Form and Instruction
10-day OMB Spanish NHANES final 0911 2015.docx
10-day OMB Spanish NHANES final 0911 2015
IC Document
Appendix 4 Informed Consent Spanish NHANES.docx
Appendix 4 Informed Consent Spanish NHANES
IC Document
Appendix 7 Special Consent Spanish 092315.docx
Appendix 7 Special Consent Spanish 092315
IC Document
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
2017 NHANES Health Behaviors Cognitive Interviewing Study/Spanish
Agency IC Tracking Number:
16CC
IC Status:
New
Obligation to Respond:
Voluntary
CFR Citation:
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Form and Instruction
0920-0222
Appendix 1 Questionnaire Spanish NHANES 100215
Appendix 1 Questionnaire Spanish NHANES 100215.docx
Yes
Yes
Fillable Printable
Form and Instruction
0920-0222
Appendix 2a&b Ad&Flyer Spanish NHANES
Appendix 2a&b Ad&Flyer Spanish NHANES.docx
Yes
Yes
Fillable Printable
Form and Instruction
0920-0222
Appendix 3 Telephone Screener Spanish NHANES 100215
Appendix 3 Telephone Screener Spanish NHANES 100215.docx
Yes
Yes
Fillable Printable
Form and Instruction
0920-0222
Appendix 5 Resp Data Collection Sheet Spanish NHANES
Appendix 5 Resp Data Collection Sheet Spanish NHANES.docx
Yes
Yes
Fillable Printable
Instruction
ALQ1 Flashcard Spanish.pdf
Yes
Yes
Fillable Printable
Instruction
Appendix 6 Thank You letter Spanish NHANES.docx
Yes
Yes
Fillable Printable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Public Health Monitoring
Privacy Act System of Records
Title:
Health and Demographic Surveys Conducted in Probability Samples of the U. S. Population 09-20-0164
FR Citation:
49 FR 37693
Number of Respondents:
68
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
100 %
Approved
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
68
0
68
0
0
0
Annual IC Time Burden (Hours)
24
0
24
0
0
0
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
10-day OMB Spanish NHANES final 0911 2015
10-day OMB Spanish NHANES final 0911 2015.docx
10/28/2015
Appendix 4 Informed Consent Spanish NHANES
Appendix 4 Informed Consent Spanish NHANES.docx
10/28/2015
Appendix 7 Special Consent Spanish 092315
Appendix 7 Special Consent Spanish 092315.docx
10/28/2015
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.