Information Collection

CQDER - Opioid Plus Card Sort

IC 231689 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⚠️ Notice: This information collection may be referencing outdated material.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
Form 0920-0222 CQDER - Opioid Plus Card Sort	Form and Instruction
0920-0222 Opioid Questionnaire - Card Sort Attach 1 - Opioid Qnne 050118.doc	Form and Instruction
0920-0222 Telephone Screener Attach 3ab - Telephone Screener.docx	Form and Instruction
Attach 2 - Ad-flyer.doc Study Advertisement / Flyer	IC Document
Attach 4 - Informed Consent.doc Informed Consent	IC Document
Attach 5 - Resp Data Collect Sheet.doc Respondent Data Colletion Sheet	IC Document
Attach 6 - Thank you letter 042018.doc Thank You Letter	IC Document
Attach 7 - Card Sort 060518.docx Opioid Card Sort	IC Document
Opioid Plus Card Sort 10-day 060818.docx Opioid Plus Card Sort - 10 Day Letter	IC Document

IC Title:

CQDER - Opioid Plus Card Sort

Agency IC Tracking Number:

0920-0222-18ANT

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	0920-0222	Opioid Questionnaire - Card Sort	Attach 1 - Opioid Qnne 050118.doc	NA	No		Paper Only
Form and Instruction	0920-0222	Telephone Screener	Attach 3ab - 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: 560

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	560	560
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
Study Advertisement / Flyer	Attach 2 - Ad-flyer.doc	06/11/2018
Informed Consent	Attach 4 - Informed Consent.doc	06/11/2018
Respondent Data Colletion Sheet	Attach 5 - Resp Data Collect Sheet.doc	06/11/2018
Thank You Letter	Attach 6 - Thank you letter 042018.doc	06/11/2018
Opioid Card Sort	Attach 7 - Card Sort 060518.docx	06/11/2018
Opioid Plus Card Sort - 10 Day Letter	Opioid Plus Card Sort 10-day 060818.docx	06/11/2018

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