Information Collection

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

IC 227302 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⚠️ Notice: This information collection may be referencing outdated material.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
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

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:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.