Information Collection

Cognitive testing of Confidentiality Pledge, Round 2

IC 223727 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⚠️ Notice: This information collection may be referencing outdated material.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 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

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:

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 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 %

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
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.