CQDER - Opioid Plus Card Sort

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⚠️ Notice: This information collection may be referencing outdated material.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

Information Collection (IC) Details

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:

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 %

	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

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.