Information Collection

2017 NHANES Health Behaviors Cognitive Interviewing Study/Spanish

IC 218756 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⚠️ Notice: This information collection may be referencing outdated material.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 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

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:

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	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

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 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	68	68
Annual IC Time Burden (Hours)	24	24
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.