Questionnaire Design and Evaluation Research on Injury for the National Health Interview Survey (NHIS)

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⚠️ Notice: This information collection may be referencing outdated material.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
Questionnaire Design and Evaluation Research on Injury for the National Health Interview Survey (NHIS) Form and Instruction
Telephone Screener Attach 3 - Telephone Screener.docx Form and Instruction
Questionnaire - Injury Questions to Evaluate Attach 1 - Questionnaire.docx Form and Instruction
Attach 2a&b Ads&Flyers.docx Study Participation Ad/Flyer IC Document
Attach 4 - Informed Consent.docx Informed Consent - Interview IC Document
Attach 7 - Spec Consent.docx Special Consent for Expanded Use of Video and Audio Recordings IC Document
Attach 5 - Resp Data Collect Sheet.docx Respondent Data Collection Sheet IC Document
Attach 6 - Thank You Ltr.docx Thank You Letter IC Document
10-day letter NHIS Injury 102617.docx 10-Day Letter IC Document

Information Collection (IC) Details

IC Title:	Questionnaire Design and Evaluation Research on Injury for the National Health Interview Survey (NHIS)	Agency IC Tracking Number:	0920-0222-18DO

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	NA	Questionnaire - Injury Questions to Evaluate	Attach 1 - Questionnaire.docx	NA	No		Paper Only
Form and Instruction	NA	Telephone Screener	Attach 3 - Telephone Screener.docx	NA	No		Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title: 09-20-0164 - Health and Demographic Surveys Conducted in Probability Samples of the U. S. Population	FR Citation: 49 FR 37693

Number of Respondents: 68	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	68	68
Annual IC Time Burden (Hours)	24	24
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Study Participation Ad/Flyer	Attach 2a&b Ads&Flyers.docx	10/27/2017
Informed Consent - Interview	Attach 4 - Informed Consent.docx	10/27/2017
Special Consent for Expanded Use of Video and Audio Recordings	Attach 7 - Spec Consent.docx	10/27/2017
Respondent Data Collection Sheet	Attach 5 - Resp Data Collect Sheet.docx	10/27/2017
Thank You Letter	Attach 6 - Thank You Ltr.docx	10/27/2017
10-Day Letter	10-day letter NHIS Injury 102617.docx	10/27/2017

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