National Health Interview Survey

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Methodological Projects - Adult Family Member	Form	Modified	Available
Reinterview Survey	Form and Instruction	Modified	Repair queued
New Supplements and Core Changes	Form and Instruction	Modified	Repair queued
Sample Child Core Questionnaire	Form and Instruction	Modified	Available
Sample Adult Core Questionnaire	Form and Instruction	Modified	Available
Family Core Questionnaire	Form and Instruction	Modified	Repair queued
OMB Statement and Screener	Form and Instruction	Removed	Available
Att 8 - Sample Redesign Description.pdf	Supplementary Document	Uploaded 2015-12-08	Available
Att 7 - ERB Approval.pdf	Supplementary Document	Uploaded 2015-12-08	Available
Att 6b - Informational Materials.pdf	Supplementary Document	Uploaded 2015-12-08	Available
Att 6a - Advance Letters.pdf	Supplementary Document	Uploaded 2015-12-08	Available
Att 4g - Wearables Pilot Description.pdf	Supplementary Document	Uploaded 2015-12-08	Available
Att 4e - Flashcards.pdf	Supplementary Document	Uploaded 2015-12-08	Available
Att 4d - Supplement Questions.pdf	Supplementary Document	Uploaded 2015-12-08	Available
Att 3 - Core and Supplement Changes.pdf	Supplementary Document	Uploaded 2015-12-08	Available
Att 2b - Public Comments 090315.txt	Supplementary Document	Uploaded 2015-12-08	Available
Att 2a - 60 Day Notice.pdf	Supplementary Document	Uploaded 2015-12-08	Available
Att 1 - Legislative Mandates.pdf	Supplementary Document	Uploaded 2015-12-08	Available
2016 NHIS SSB 123015 clean.doc	Supporting Statement B	Uploaded 2015-12-30	Available
2016 NHIS SSA 123015 clean.docx	Supporting Statement A	Uploaded 2015-12-30	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
214142	Methodological Projects - Adult Family Member	Form	Modified
214116	Reinterview Survey	Form and Instruction	Modified
214115	New Supplements and Core Changes	Form and Instruction	Modified
214114	Sample Child Core Questionnaire	Form and Instruction	Modified
214113	Sample Adult Core Questionnaire	Form and Instruction	Modified
214112	Family Core Questionnaire	Form and Instruction	Modified
214111	OMB Statement and Screener	Form and Instruction	Removed

ICR Details

OMB Control No: 0920-0214	ICR Reference No: 201512-0920-002
Status: Historical Active	Previous ICR Reference No: 201504-0920-008
Agency/Subagency: HHS/CDC	Agency Tracking No: 0214
Title: National Health Interview Survey
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 01/05/2016
	Date Received in OIRA: 12/10/2015
Terms of Clearance: CDC/NCHS may use the non-substantive change mechanism to modify existing questions, including those designed to add depth/additional detail and cycle in and out supplemental modules that have been used in the past years (with modest updates). If new supplemental modules, new questionnaire instruments, or modifications to the sample are anticipated, a full revision of the ICR package must be submitted to OMB. The results of the incentive experiment should be shared with OMB when available.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2019	36 Months From Approved	12/31/2017
Responses	160,000	0	163,400
Time Burden (Hours)	49,000	0	47,633
Cost Burden (Dollars)	0	0	0

---

Abstract: The Centers for Disease Control and Prevention and the National Center for Health Statistics is requesting a revision(s) of the National Health Interview Survey to; 1) implement a new sampling design, 2) conduct methodological projects (a follow-back survey, a pilot test of wearable devices, and activities pertaining to questionnaire redesign), and 3) modify selected sections of the 2016-2018 surveys through a non-substantive change request..

---

Authorizing Statute(s): US Code: 42 USC 242 Name of Law: Public Health Service Act
   PL: Pub.L. 107 - 347 511 Name of Law: Confidential Information Protection and Statistical Efficiency Act
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 53157	09/02/2015
30-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 76291	12/08/2015
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 6

table that charts list of burden

IC Title	Form No.	Form Name
OMB Statement and Screener	None	2015 OMB Statement and Screener
Sample Adult Core Questionnaire	NA	2016 Sample Adult Core Questionnaire
Methodological Projects - Adult Family Member	None	2015 Follow-back Survey
Family Core Questionnaire	NA	2016 Family Core Questionnaire
Sample Child Core Questionnaire	NA	2016 Sample Child Core Questionnaire
New Supplements and Core Changes	NA	2016 New Supplemental Questions
Reinterview Survey	NA	2016 Reinterview Questionnaire

---

ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	160,000	163,400	0	-3,400	0	0
Annual Time Burden (Hours)	49,000	47,633	0	1,367	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: Change in burden is the result of a Revision to 0920-0214. The difference is the result of not screening for minority households in the new design. There will no longer be 5 minute doorstep interview(s) on up to 10,000 addresses per year, however there is an addition of burden in 2016 for methodological activities associated with the upcoming questionnaire redesign.

---

Annual Cost to Federal Government: $42,000,000

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Yes

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

---

Common Form ICR:  No

---

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 12/10/2015

---