Cognitive Testing of Impaired Driving Questions for CDC National Center for Injury Prevention and Control (NPIPC)

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⚠️ Notice: This information collection may be referencing outdated material.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
Form 0920-0222 Cognitive Testing of Impaired Driving Questions for CDC National Center for Injury Prevention and Control (NPIPC) Form and Instruction
0920-0222 Imp Driving - Attach 3 Screener rev-kw Imp Driving - Attach 3 Screener rev-kw.docx Form and Instruction
0920-0222 Imp Driving - Attach 5 Resp Data Collection Sheet Imp Driving - Attach 5 Resp Data Collection Sheet.docx Form and Instruction
Impaired Driving 10-day ltr 041417.docx Impaired Driving 10-day ltr 041417 IC Document
Imp Driving - Attach 1 Qnne rev.docx Imp Driving - Attach 1 Qnne rev IC Document
Imp Driving - Attach 2a-c Ad&Flyers.docx Imp Driving - Attach 2a-c Ad&Flyers IC Document
Imp Driving - Attach 4 Informed Consent.docx Imp Driving - Attach 4 Informed Consent IC Document
Imp Driving - Attach 6 Thank You letter.docx Imp Driving - Attach 6 Thank You letter IC Document
Imp Driving - Attach 7 Adult Special Consent.docx Imp Driving - Attach 7 Adult Special Consent IC Document

Information Collection (IC) Details

IC Title:	Cognitive Testing of Impaired Driving Questions for CDC National Center for Injury Prevention and Control (NPIPC)	Agency IC Tracking Number:	17AEY

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
Form and Instruction	0920-0222	Imp Driving - Attach 3 Screener rev-kw	Imp Driving - Attach 3 Screener rev-kw.docx		Yes	Yes	Fillable Printable
Form and Instruction	0920-0222	Imp Driving - Attach 5 Resp Data Collection Sheet	Imp Driving - Attach 5 Resp Data Collection Sheet.docx		Yes	Yes	Fillable Printable

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: 112	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	112	112
Annual IC Time Burden (Hours)	46	46
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Impaired Driving 10-day ltr 041417	Impaired Driving 10-day ltr 041417.docx	04/20/2017
Imp Driving - Attach 1 Qnne rev	Imp Driving - Attach 1 Qnne rev.docx	04/20/2017
Imp Driving - Attach 2a-c Ad&Flyers	Imp Driving - Attach 2a-c Ad&Flyers.docx	04/20/2017
Imp Driving - Attach 4 Informed Consent	Imp Driving - Attach 4 Informed Consent.docx	04/20/2017
Imp Driving - Attach 6 Thank You letter	Imp Driving - Attach 6 Thank You letter.docx	04/20/2017
Imp Driving - Attach 7 Adult Special Consent	Imp Driving - Attach 7 Adult Special Consent.docx	04/20/2017

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