Cognitive Interviewing Study of Opioid-Related 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⚠️ Notice: This information collection may be referencing outdated material.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
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

Information Collection (IC) Details

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:

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 %

	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

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.