Information Collection

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

IC 220340 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⚠️ Notice: This information collection may be referencing outdated material.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
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

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:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.