Information Collection

HINTS 5 Cognitive Testing

IC 221003 under ICR 201511-0925-002 · OMB 0925-0589.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Attachment C Screening Questionnaire HINTS 5 Cognitive Testing	Form and Instruction
Form 2 Attachment D Consent Form HINTS 5 Cognitive Testing	Form and Instruction
Form 3 Attachment E Questionnaire Content HINTS 5 Cognitive Testing	Form and Instruction
Form 4 Attachment F Interview Protocol HINTS 5 Cognitive Testing	Form and Instruction
1 Attachment C Screening Questionnaire Attach C - Screening Questionnaire.docx	Form and Instruction
2 Attachment D Consent Form Attach D - Consent form.docx	Form and Instruction
3 Attachment E Questionnaire Content Attachment E - Questionnaire Content.docx	Form and Instruction
4 Attachment F Interview Protocol Attachment F - Interview Protocol.docx	Form and Instruction
Attachment A - Westat IRB Approval.pdf Attachment A Westat IRB Approval	IC Document
Attachment B - OHSRP Request for Determination Form.doc Attachment B OHSRP Request for Determination	IC Document
Attachment G - Recruitment Advertisement.docx Attachment G Recruitment Advertisement	IC Document
Attachment H - Reminder Letter.docx Attachment H Reminder Letter	IC Document
HINTS 5 Cog Testing Mini SSA 4-6Final.docx HINTS 5 Cognitive Testing Mini SSA	IC Document
HINTS 5 Cog Testing Mini SSB.docx HINTS 5 Cognitive Testing Mini SSB	IC Document

IC Title:

Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	1	No		Paper Only
Form and Instruction	2	No		Paper Only
Form and Instruction	3	Yes	No	Fillable Fileable
Form and Instruction	4	No		Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 60

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	60	60
Annual IC Time Burden (Hours)	58	58
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachment A Westat IRB Approval		04/11/2016
Attachment B OHSRP Request for Determination		04/11/2016
Attachment G Recruitment Advertisement		04/11/2016
Attachment H Reminder Letter		04/11/2016
HINTS 5 Cognitive Testing Mini SSA		04/11/2016
HINTS 5 Cognitive Testing Mini SSB		04/11/2016

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

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