Information Collection

Cognitive Interviewing Study of Opioid-Related Questions

IC 231306 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⚠️ Notice: This information collection may be referencing outdated material.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
Cognitive Interviewing Study of Opioid-Related Questions	Form and Instruction
Questionnaire for Cognitive Testing of Opioid Questions Attach 1 - Opioid Qnne 050118.doc	Form and Instruction
Telephone Screener for Individuals Recruited through the Attach 3ab - Newspaper Advertisement Telephone Screener 050118.docx	Form and Instruction
Respondent Data Collection Sheet (completed during the c Attach 5 - Resp Data Collect Sheet.doc	Form
Attach 2 - Ad-flyer.doc Flyer for Newspaper Recruitment Ad	IC Document
Attach 4 - Informed Consent.doc Informed Consent	IC Document
Attach 6 - Thank you letter 042018.doc Thank-you Letter for Participants	IC Document
Opioid 10-day letter 050118.docx Project Overview: 10-day Letter for Cognitive Test of Opioid Questions	IC Document

IC Title:

Cognitive Interviewing Study of Opioid-Related Questions

Agency IC Tracking Number:

0920-18AEC

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	Available Electronically?	Electronic Capability
Form and Instruction	n/a	Questionnaire for Cognitive Testing of Opioid Questions	Attach 1 - Opioid Qnne 050118.doc	No	Paper Only
Form and Instruction	n/a	Telephone Screener for Individuals Recruited through the Newspaper Ad	Attach 3ab - Newspaper Advertisement Telephone Screener 050118.docx	No	Paper Only
Form	n/a	Respondent Data Collection Sheet (completed during the cognitive interview)	Attach 5 - Resp Data Collect Sheet.doc	No	Paper Only

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: 360

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	360	360
Annual IC Time Burden (Hours)	230	230
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Flyer for Newspaper Recruitment Ad	Attach 2 - Ad-flyer.doc	05/02/2018
Informed Consent	Attach 4 - Informed Consent.doc	05/02/2018
Thank-you Letter for Participants	Attach 6 - Thank you letter 042018.doc	05/02/2018
Project Overview: 10-day Letter for Cognitive Test of Opioid Questions	Opioid 10-day letter 050118.docx	05/02/2018

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