Information Collection

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

IC 228813 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⚠️ Notice: This information collection may be referencing outdated material.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
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

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:

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	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 %

table that charts list of burden
	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

table that charts IC Documents
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.