Information Collection

2017 NHANES Health Behaviors Cognitive Interviewing Study

IC 221510 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⚠️ Notice: This information collection may be referencing outdated material.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
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

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:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.