Information Collection

Center for Questionnaire Design and Evaluation Research (CQDER) CMS 10-day Letter

IC 221257 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⚠️ Notice: This information collection may be referencing outdated material.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
CQDER CMS Att 2ab Recruit Msg.docx	Instruction
0920-16AEE CQDER CMS Att 3ab Telephone Screener CQDER CMS Att 3ab Telephone Screener.docx	Form and Instruction
0920-16AEE CQDER CMS Att 5ab Resp Data Collect CQDER CMS Att 5ab Resp Data Collect.docx	Form and Instruction
0920-16AEE CQDER CMS Att 1ab Qnne wshowcards CQDER CMS Att 1ab Qnne wshowcards.docx	Form and Instruction
CQDER CMS 10-day Letter 042016.docx CQDER CMS 10-day Letter 042016	IC Document
CQDER CMS Att 4ab Informed Consent 041916.docx CQDER CMS Att 4ab Informed Consent	IC Document
CQDER CMS Att 6ab Thank You Letter.docx CQDER CMS Att 6ab Thank You Letter	IC Document

IC Title:

Center for Questionnaire Design and Evaluation Research (CQDER) CMS 10-day Letter

Agency IC Tracking Number:

16AEE

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
Instruction			CQDER CMS Att 2ab Recruit Msg.docx	Yes	Yes	Fillable Printable
Form and Instruction	0920-16AEE	CQDER CMS Att 3ab Telephone Screener	CQDER CMS Att 3ab Telephone Screener.docx	Yes	Yes	Fillable Printable
Form and Instruction	0920-16AEE	CQDER CMS Att 5ab Resp Data Collect	CQDER CMS Att 5ab Resp Data Collect.docx	Yes	Yes	Fillable Printable
Form and Instruction	0920-16AEE	CQDER CMS Att 1ab Qnne wshowcards	CQDER CMS Att 1ab Qnne wshowcards.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: 100

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	100	100
Annual IC Time Burden (Hours)	50	50
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
CQDER CMS 10-day Letter 042016	CQDER CMS 10-day Letter 042016.docx	04/26/2016
CQDER CMS Att 4ab Informed Consent	CQDER CMS Att 4ab Informed Consent 041916.docx	04/26/2016
CQDER CMS Att 6ab Thank You Letter	CQDER CMS Att 6ab Thank You Letter.docx	04/26/2016

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