Information Collection

Cognitive Testing of Middle Eastern North African (MENA) Questions

IC 224421 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⚠️ Notice: This information collection may be referencing outdated material.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
Cognitive Testing of Middle Eastern North African (MENA) Questions	Form
Questions to be cognitively tested MENA Attach 1 - Qnne.docx	Form
Telephone screening script MENA Attach 3 -Screener.docx	Form
Respondent data collection sheet MENA Attach 5 - Resp Data Collection Sheet.docx	Form
MENA Attach 2ab - adsflyers.docx Advertisements and Flyers	IC Document
MENA Attach 4 - Consent.docx Adult Informed Consent	IC Document
MENA Attach 7 - Adult Special Consent.docx Adult Special Consent	IC Document
MENA Attach 6 - Thank You letter.docx Thank You Letter	IC Document
MENA 10-day letter rev.docx Request for OMB Approval - Letter to Dr Schwab	IC Document
Additional_Clarification_20161213.docx Additional Protocol Clarifications	IC Document
Terms of Clearance.docx Terms of Clearance	IC Document

IC Title:

Cognitive Testing of Middle Eastern North African (MENA) Questions

Agency IC Tracking Number:

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
Form	None	Questions to be cognitively tested	MENA Attach 1 - Qnne.docx	Yes	Yes	Fillable Fileable
Form	None	Telephone screening script	MENA Attach 3 -Screener.docx	Yes	Yes	Fillable Fileable
Form	None	Respondent data collection sheet	MENA Attach 5 - Resp Data Collection 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 the U.S. Population 09-20-0164

FR Citation: 49 FR 37693

Number of Respondents: 316

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	316	316
Annual IC Time Burden (Hours)	118	118
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Advertisements and Flyers	MENA Attach 2ab - adsflyers.docx	11/15/2016
Adult Informed Consent	MENA Attach 4 - Consent.docx	11/15/2016
Adult Special Consent	MENA Attach 7 - Adult Special Consent.docx	11/15/2016
Thank You Letter	MENA Attach 6 - Thank You letter.docx	11/15/2016
Request for OMB Approval - Letter to Dr Schwab	MENA 10-day letter rev.docx	11/15/2016
Additional Protocol Clarifications	Additional_Clarification_20161213.docx	12/13/2016
Terms of Clearance	Terms of Clearance.docx	12/13/2016

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