Cognitive Testing of NHIS health care utilization smoking, and selected child questions

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⚠️ Notice: This information collection may be referencing outdated material.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 092017AUC Cognitive Testing of NHIS health care utilization smoking, and selected child questions Form and Instruction
092017AUC Attach 3 Telephone Screener vcb 051017kw no confid pld u Attach 3 Telephone Screener vcb 051017kw no confid pld update.docx Form and Instruction
0920-17AUC Attach 3 Telephone Screener vcb 051017kw no confid pld u Attach 5 Resp Data Collect Sheet.docx Form and Instruction
10-day letter HIS Redesign 0626 2017.docx 10-day letter HIS Redesign 0626 2017 IC Document
Attach 1 HIS Redesign Qnne vcb 051017kw no confid pledge change.docx Attach 1 HIS Redesign Qnne vcb 051017kw no confid pledge change IC Document
Attach 2a&b Adv&Flyer.docx Attach 2a&b Adv&Flyer IC Document
Attach 4 Informed Consent vcb 051017kw no confid pled update.docx Attach 4 Informed Consent vcb 051017kw no confid pled update IC Document
C.docx C IC Document
Attach 6 Thank You Letter.docx Attach 6 Thank You Letter IC Document

Information Collection (IC) Details

IC Title:	Cognitive Testing of NHIS health care utilization smoking, and selected child questions	Agency IC Tracking Number:	0920-17AUC

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	092017AUC	Attach 3 Telephone Screener vcb 051017kw no confid pld update	Attach 3 Telephone Screener vcb 051017kw no confid pld update.docx		Yes	Yes	Fillable Fileable
Form and Instruction	0920-17AUC	Attach 3 Telephone Screener vcb 051017kw no confid pld update	Attach 5 Resp Data Collect 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: 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
10-day letter HIS Redesign 0626 2017	10-day letter HIS Redesign 0626 2017.docx	06/27/2017
Attach 1 HIS Redesign Qnne vcb 051017kw no confid pledge change	Attach 1 HIS Redesign Qnne vcb 051017kw no confid pledge change.docx	06/27/2017
Attach 2a&b Adv&Flyer	Attach 2a&b Adv&Flyer.docx	06/27/2017
Attach 4 Informed Consent vcb 051017kw no confid pled update	Attach 4 Informed Consent vcb 051017kw no confid pled update.docx	06/27/2017
C	C.docx	06/27/2017
Attach 6 Thank You Letter	Attach 6 Thank You Letter.docx	06/27/2017

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