Information Collection

Congitive Testing of Confidentiality Pledges

IC 221825 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⚠️ Notice: This information collection may be referencing outdated material.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 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

IC Title:

Congitive Testing of Confidentiality Pledges

Agency IC Tracking Number:

16AQC

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
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 %

table that charts list of burden
	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

table that charts IC Documents
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.