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⚠️ Notice: This information collection may be referencing outdated material.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

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

Information Collection (IC) Details

View Information Collection (IC)

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:

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 %

	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

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.