Cognitive testing of Confidentiality Pledge, Round 2

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⚠️ Notice: This information collection may be referencing outdated material.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 3 Telehphone Screener.docx Other-WORD
Attach 5 Resp Data Collect Sheet.docx Other-WORD
Attach 1 092616.docx Att 1_ Confidentiality Pledge IC Document
Attach 2 Advertisement&flyer.docx Att 2_Ads & Flyers IC Document
Attach 4 Informed Consent.docx Att 4_Informed Consent IC Document
Attach 6 Thank You Letter.docx Att 6_Thank you Letter IC Document
Attach 7 Spec Consent.docx Att 7_Spec Consent IC Document
Confid Pledge 10-day letter 0928 2016.docx Request for Approval IC Document

Information Collection (IC) Details

IC Title:	Cognitive testing of Confidentiality Pledge, Round 2	Agency IC Tracking Number:	16BFN

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 3 Telehphone Screener.docx		Yes	Yes	Fillable Printable
Other-WORD			Attach 5 Resp Data Collect Sheet.docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title: 09-06-0164 Health and Demographic Surveys Condcuted in Probability Samples of the U.S. 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
Att 1_ Confidentiality Pledge	Attach 1 092616.docx	09/28/2016
Att 2_Ads & Flyers	Attach 2 Advertisement&flyer.docx	09/28/2016
Att 4_Informed Consent	Attach 4 Informed Consent.docx	09/28/2016
Att 6_Thank you Letter	Attach 6 Thank You Letter.docx	09/28/2016
Att 7_Spec Consent	Attach 7 Spec Consent.docx	09/28/2016
Request for Approval	Confid Pledge 10-day letter 0928 2016.docx	09/28/2016

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