Testing of questions on cognitive functioning and other questions for the National Health Interview Survey (NHIS)

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⚠️ Notice: This information collection may be referencing outdated material.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
Testing of questions on cognitive functioning and other questions for the National Health Interview Survey (NHIS) Form and Instruction
NHIS Cognitive Functioning and other questions to be cog HIS Cog Func Att 1 Qnne 022416.docx Form and Instruction
Telephone Screening Script HIS Cog Func Att 3 Screener.docx Form and Instruction
HIS Cog Func Att 4 consent.docx Informed Consent IC Document
HIS Cog Func Att 5 Spec Con.docx Special Consent for Expanded Use of Video and Audio Recordings IC Document
HIS Cog Func Att 2 Ad&flyer.docx Advertisement - Study Participants IC Document
HIS Cog Dis 10-day letter 022916.docx Request - Questionnaire Design and Evaluation Researchcognitive functioning and other questions for (NHIS) IC Document

Information Collection (IC) Details

IC Title:	Testing of questions on cognitive functioning and other questions for the National Health Interview Survey (NHIS)	Agency IC Tracking Number:	16SS

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	NA	NHIS Cognitive Functioning and other questions to be cognitively tested	HIS Cog Func Att 1 Qnne 022416.docx	NA	Yes	Yes	Fillable Fileable
Form and Instruction	NA	Telephone Screening Script	HIS Cog Func Att 3 Screener.docx	NA	Yes	Yes	Fillable Fileable

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	FR Citation: 49 FR 37693

Number of Respondents: 112	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	112	112
Annual IC Time Burden (Hours)	46	46
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Informed Consent	HIS Cog Func Att 4 consent.docx	03/01/2016
Special Consent for Expanded Use of Video and Audio Recordings	HIS Cog Func Att 5 Spec Con.docx	03/01/2016
Advertisement - Study Participants	HIS Cog Func Att 2 Ad&flyer.docx	03/01/2016
Request - Questionnaire Design and Evaluation Researchcognitive functioning and other questions for (NHIS)	HIS Cog Dis 10-day letter 022916.docx	03/01/2016

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