Information Collection

Cognitive Interviewing Study of Opioid-Related Questions (Spanish Version)

IC 231500 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⚠️ Notice: This information collection may be referencing outdated material.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 (Spanish Version)	Form and Instruction
Sample screening script for respondent contact Cognitive Attach 3 Spanish Telephone Screener 051518.docx	Form and Instruction
Spanish Questions to be cognitively tested Attach 1 Spanish Questionnaire.doc	Form and Instruction
Spanish Respondent Data Collection Sheet Attach 5 Spanish Resp Data Collect.docx	Form and Instruction
Spanish Opioid 10-day 051518.docx Project Description (10-day Letter)	IC Document
Attach 2 Spanish Advertisement.docx Recruitment Ad for Spanish Speaking Participants	IC Document
Attach 4 Spanish Informed Consent.docx Informed Consent Form for Spansih Study	IC Document
Attach 6 Spanish Thank You Letter.docx Thank You Letter	IC Document

IC Title:

Cognitive Interviewing Study of Opioid-Related Questions (Spanish Version)

Agency IC Tracking Number:

0920-18AHJ

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	Sample screening script for respondent contact Cognitive interviewing study of opioid use and pain questions	Attach 3 Spanish Telephone Screener 051518.docx	No	Paper Only
Form and Instruction	n/a	Spanish Questions to be cognitively tested	Attach 1 Spanish Questionnaire.doc	No	Paper Only
Form and Instruction	n/a	Spanish Respondent Data Collection Sheet	Attach 5 Spanish Resp Data Collect.docx	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: 96

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	96	96
Annual IC Time Burden (Hours)	68	68
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Project Description (10-day Letter)	Spanish Opioid 10-day 051518.docx	05/17/2018
Recruitment Ad for Spanish Speaking Participants	Attach 2 Spanish Advertisement.docx	05/17/2018
Informed Consent Form for Spansih Study	Attach 4 Spanish Informed Consent.docx	05/17/2018
Thank You Letter	Attach 6 Spanish Thank You Letter.docx	05/17/2018

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