Congitive Testing of Confidentiality Pledges

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⚠️ Notice: This information collection may be referencing outdated material.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 1 Confid Pledge Materials 060316.docx Other-Testing Materials
Attach 3 Telehphone Screener.docx Other-Screening script
Respondent data collection sheet Attach 5 Resp Data Collect Sheet.docx Form
Confid Pledge 10-day letter 060616.docx Letter to Dr. Schwab IC Document
Attach 2 Advertisement&flyer.docx Advertisement/flyer IC Document
Attach 4 Informed Consent.docx Consent script IC Document
Attach 6 Thank You Letter.docx Thank you letter IC Document
Attach 7 Spec Consent.docx Special consent for expanded use of recordings IC Document

Information Collection (IC) Details

IC Title:	Congitive Testing of Confidentiality Pledges	Agency IC Tracking Number:	16AQC

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Testing Materials			Attach 1 Confid Pledge Materials 060316.docx	Yes	Yes	Fillable Fileable
Other-Screening script			Attach 3 Telehphone Screener.docx	Yes	Yes	Fillable Fileable
Form	none	Respondent data collection sheet	Attach 5 Resp Data Collect Sheet.docx	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 hte US Population	FR Citation: 49 FR 37693

Number of Respondents: 68	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	68	68
Annual IC Time Burden (Hours)	24	24
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Letter to Dr. Schwab	Confid Pledge 10-day letter 060616.docx	06/08/2016
Advertisement/flyer	Attach 2 Advertisement&flyer.docx	06/08/2016
Consent script	Attach 4 Informed Consent.docx	06/08/2016
Thank you letter	Attach 6 Thank You Letter.docx	06/08/2016
Special consent for expanded use of recordings	Attach 7 Spec Consent.docx	06/08/2016

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