2017 NHANES Health Behaviors Cognitive Interviewing Study

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⚠️ Notice: This information collection may be referencing outdated material.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
Attach 1ab Questionnaire 042716.docx Other-WORD
Attach 4ab telephone screener.docx Other-WORD
Attach 2ab Hand Card #ALQ1 Eng_Span.pdf Att2_Questionnaire - Spanish Version IC Document
Attach 3a-d Adv&Flyer.docx Att 3a-d_Flyer (English /Spanish) IC Document
Attach 5ab informed consent.docx Att 5a-b_Consent Form IC Document
Attach 6ab Resp Data Collection Sheet.docx Att 6a-b_Respondent Data Collection Sheet (Sample) IC Document
Attach 7ab Thank You letter.docx Att 7a-b_Thank You Letters (English/Spanish) IC Document
Attach 8ab Special Consent.docx Att 8a-b_Special Consent IC Document
10-day NHANES letter 051016.docx Request for Approval IC Document

Information Collection (IC) Details

IC Title:	2017 NHANES Health Behaviors Cognitive Interviewing Study	Agency IC Tracking Number:	16AJD

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
Other-WORD			Attach 1ab Questionnaire 042716.docx		Yes	Yes	Fillable Fileable
Other-WORD			Attach 4ab telephone screener.docx		No		Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 126	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	126	126
Annual IC Time Burden (Hours)	38	38
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Att2_Questionnaire - Spanish Version	Attach 2ab Hand Card #ALQ1 Eng_Span.pdf	05/13/2016
Att 3a-d_Flyer (English /Spanish)	Attach 3a-d Adv&Flyer.docx	05/13/2016
Att 5a-b_Consent Form	Attach 5ab informed consent.docx	05/13/2016
Att 6a-b_Respondent Data Collection Sheet (Sample)	Attach 6ab Resp Data Collection Sheet.docx	05/13/2016
Att 7a-b_Thank You Letters (English/Spanish)	Attach 7ab Thank You letter.docx	05/13/2016
Att 8a-b_Special Consent	Attach 8ab Special Consent.docx	05/13/2016
Request for Approval	10-day NHANES letter 051016.docx	05/13/2016

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