Generic Clearance for Questionnaire Pretesting Research

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 1 Select Survey Items	Form and Instruction	New	Available
Form 4 Cognitive Interview Version 3	Form and Instruction	New	Available
Form 3 Cognitive Interview Version 2	Form and Instruction	New	Available
Form 2 Cognitive Interview Version 1	Form and Instruction	New	Available
Form 1 Screener Survey	Form and Instruction	New	Available
Form 1 Mail Materials	Form and Instruction	New	Available
Form 6 Online Questionnaire w/o citizenship	Form and Instruction	New	Available
Form 5 Online Questionnaire w/ citizenship	Form and Instruction	New	Available
Form 4 2020 Census Follow Up Survey w/o citizenship	Form and Instruction	New	Available
Form 3 2020 Census Follow Up Survey w/ citizenship	Form and Instruction	New	Available
Form 2 2020 Census Draft w/o citizenship	Form and Instruction	New	Available
Form 1 2020 Census Draft w/ citizenship	Form and Instruction	New	Available
Form 1 2017 CFS Instrument	Form and Instruction	New	Available
Form 5 Satisfaction Questionnaire	Form and Instruction	New	Available
Form 4 Mobile Experience Questionnaire	Form and Instruction	New	Available
Form 3 Demographic Questionnaire	Form and Instruction	New	Available
Form 2 Paper Questionnaire	Form and Instruction	New	Available
Form 1 Log On Letter	Form and Instruction	New	Available
Form 2 Example Survey Questions	Form and Instruction	New	Available
Form 1 Example Chart	Form and Instruction	New	Available
Form 1 Mailing Materials	Form and Instruction	New	Available
Form 1 Globalization Module draft	Form and Instruction	New	Available
Form 3 Flash Cards	Form and Instruction	New	Available
Form 2 Protocol V2 (Renter)	Form and Instruction	New	Available
Form 1 Protocol V1 (Owner)	Form and Instruction	New	Available
Form 1 Robotics Questions	Form and Instruction	New	Available
Form 1 Protocol and Questionnaire	Form and Instruction	New	Available
Form 6 Tech Capabilities List	Form and Instruction	New	Available
Form 5 Digital Tech Cards	Form and Instruction	New	Available
Form 4 Business Strategies Handout	Form and Instruction	New	Available
Form 3 Barriers and Drivers Handout	Form and Instruction	New	Available
Form 2 Innovation Handout	Form and Instruction	New	Available
Form 1 Revised Innovation Module	Form and Instruction	New	Available
Form 4 Satisfaction Questionnaire	Form	New	Available
Form 3 Debriefing Questionnaire	Form	New	Available
Form 2 Internet Use Questionnaire	Form	New	Available
Form 1 Demographics Questionnaire	Form	New	Available
Form 1 Screenshots of Instrument	Form and Instruction	New	Available
Form 2 Cognitive Interviewing Protocol	Form and Instruction	New	Available
Form 1 Focus Group Protocol	Form and Instruction	New	Available
Form 4 Form MEPS 11s	Form and Instruction	New	Available
Form 3 Form MEPS 11	Form and Instruction	New	Available
Form 2 Form MEPS 10s	Form and Instruction	New	Available
Form 1 Form MEPS 10	Form and Instruction	New	Available
Form 9 Preference of Address Display Question	Form and Instruction	New	Available
Form 8 Satisfaction with Instrument Questionnaire	Form and Instruction	New	Available
Form 7 Version 6 of Address Display	Form and Instruction	New	Available
Form 6 Version 5 of Address Display	Form and Instruction	New	Available
Form 5 Version 4 of Address Display	Form and Instruction	New	Available
Form 4 Version 3 of Address Display	Form and Instruction	New	Available
Form 3 Version 2 of Address Display	Form and Instruction	New	Available
Form 2 Version 1 of Address Display	Form and Instruction	New	Available
Form 1 Mailing Materials	Form and Instruction	New	Available
Form 6 Web Probe Testing - Screencaps of Web Testing	Form and Instruction	New	Available
Form 5 Web Probe Testing - Screencap of Introduction to Web Survey	Form and Instruction	New	Available
Form 3 Cog Testing - Demographics Questionnaire	Form and Instruction	New	Available
Form 2 Cog Testing - Web Form of Census Tracking Questionnaire	Form and Instruction	New	Available
Form 1 Cog Testing - Census Tracking Questionnaire	Form and Instruction	New	Available
Form 4 Web Probe Testing - Language Questions for Web	Form and Instruction	New	Available
Form 1 Online Instrument	Form and Instruction	New	Available
Form 1 Modified ACS Paper Form	Form and Instruction	New	Available
Form 2 Attachment C - SAS Questionnaire	Form	New	Available
Form 1 Attachment A - Proposed Telemedicine Questions for SAS	Form	New	Available
Form 4 Alternative Cover Image 2	Form and Instruction	New	Available
Form 3 Alternative Cover Image 1	Form and Instruction	New	Available
Form 2 Alternative Full page Coversheet w/ Questionnaire (beginning)	Form and Instruction	New	Available
Form 1 Questionnaire	Form and Instruction	New	Available
Form 1 Screeners part A and part B	Form	New	Available
Form 1 QSPP Draft Questionnaire	Form and Instruction	New	Available
Form 11 Perforated Mockup 2	Form and Instruction	New	Available
Form 10 Perforated Mockup 1	Form and Instruction	New	Available
Form 9 NonPerforated Mockup 2	Form and Instruction	New	Available
Form 8 NonPerforated Mockup 1	Form and Instruction	New	Available
Form 7 Standard Treatments A and D	Form and Instruction	New	Available
Form 6 Experimental Treatment C	Form and Instruction	New	Available
Form 5 Experimental Treatment B - Perforated Mockup 2	Form and Instruction	New	Available
Form 4 Experimental Treatment B - Perforated Mockup 1	Form and Instruction	New	Available
Form 3 Experimental Treatment B - NonPerforated Mockup 2	Form and Instruction	New	Available
Form 2 Experimental Treatment B - NonPerforated Mockup 1	Form and Instruction	New	Available
Form 1 Screener Card	Form and Instruction	New	Available
Form 1 E-Commerce Questions	Form	New	Available
Form 1 2017 ABS Questionnaire	Form and Instruction	New	Available
Form 1 NAPCS Instrument Screens	Form and Instruction	New	Available
Form 4 2017 MEPS-10S Form	Form and Instruction	New	Available
Form 3 2017 MEPS-10 Form	Form and Instruction	New	Available
Form 2 2018 MEPS-10S Form	Form and Instruction	New	Available
Form 1 2018 MEPS-10 Form	Form and Instruction	New	Available
Form 1 Test materials as seen by respondents	Form and Instruction	New	Available
Form 3 Attachment D - Technology Module Questionnaire	Form and Instruction	New	Available
Form 2 ABS R and D Questionnaire	Form and Instruction	New	Available
Form 1 ABS Questionnaire	Form and Instruction	New	Available
Form 1 Privacy and Confidentiality Questionnaire	Form and Instruction	New	Available
Form 2 Leased / Temporary Employees Questionnaire	Form and Instruction	New	Available
Form 1 Aritificial Intelligence Questionnaire	Form and Instruction	New	Available
Form 1 Protocol and Questionnaire	Form and Instruction	New	Available
Form 2 ACS Respondent Feedback items at end of ACS Questionnaire	Form and Instruction	New	Available
Form 1 Entire ACS Questionnaire	Form and Instruction	New	Available
Form 4 eResponse User Manual	Form and Instruction	New	Available
Form 3 Invitation Letter	Form and Instruction	New	Available
Form 2 eResponse Reporting Template	Form and Instruction	New	Available
Form 1 2018 GQE eResponse Site	Form and Instruction	New	Available
Form 1 BUH MockUp	Form and Instruction	New	Available
Form 1 FGP Questions from Econ Census	Form	New	Available
Form 4 Satisfaction Questionnaire	Form and Instruction	New	Available
Form 3 Mobile Experience Questionnaire	Form and Instruction	New	Available
Form 2 Demographics Questionnaire	Form and Instruction	New	Available
Form 1 Instrument Debriefing Screens	Form and Instruction	New	Available
Form 3 ACS Questionnaire From Q29 V2	Form and Instruction	New	Available
Form 2 ACS Questionnaire From Q29 V1	Form and Instruction	New	Available
Form 1 ACS Questionnaire Up to Q28	Form and Instruction	New	Available
Form 1 Questionnaire	Form and Instruction	New	Available
Form 1 Question	Form and Instruction	New	Available
Form 1 Econ Census Web Screens	Form and Instruction	New	Available
Form 4 Satisfaction Questionnaire	Form	New	Available
Form 3 Debriefing Questionnaire	Form	New	Available
Form 2 Internet Experience Questionnaire	Form	New	Available
Form 1 Demographic Questionnaire	Form	New	Available
Form 1 Instrument screenshots	Form	New	Available
Form 1 Protocol and Questionnaire	Form and Instruction	New	Available
Form 6 Satisfaction Questionnaire	Form and Instruction	New	Available
Form 5 Demographic Questionnaire	Form and Instruction	New	Available
Form 4 Questionnaire V4	Form and Instruction	New	Available
Form 3 Questionnaire V3	Form and Instruction	New	Available
Form 2 Questionnaire V2	Form and Instruction	New	Available
Form 1 Questionnaire V1	Form and Instruction	New	Available
Form 4 Consent Form	Form and Instruction	New	Available
Form 3 Capitol Stock Questions	Form and Instruction	New	Available
Form 1 BRDIS 2016	Form and Instruction	New	Available
Form 2 Geography Questions	Form and Instruction	New	Available
Form Comment and Feedba Comment and Feedback Question	Form	New	Available
Form 2017 ACS form 2017 ACS form	Form	New	Available
Form 2 Internet and Mobile Experience Questionnaire	Form and Instruction	New	Available
Form 1 Demographic Questionnaire	Form and Instruction	New	Available
Form 3 Video Satisfaction Questionnare	Form and Instruction	New	Available
Form 2 Usability Tasks	Form	New	Available
Form 1 Video Screenshots	Form	New	Available
Form 2 Confidentiality Statements in English	Form and Instruction	New	Available
Form 1 Privacy Act Test Language and FAQ Context	Form and Instruction	New	Available
Form 4 MEPS-11S	Form and Instruction	New	Available
Form 3 MEPS-11	Form and Instruction	New	Available
Form 2 MEPS-10S	Form and Instruction	New	Available
Form 1 MEPS-10	Form and Instruction	New	Available
Form 4 Version D Questions	Form and Instruction	New	Available
Form 3 Version C Questions	Form and Instruction	New	Available
Form 2 Version B Questions	Form and Instruction	New	Available
Form 1 Version A Questions	Form and Instruction	New	Available
Form 1 Protocol	Form and Instruction	New	Available
Form 1 Privacy Concerns Questionnaire	Form and Instruction	New	Available
Form 4 NSSRN Questionnaire	Form and Instruction	New	Available
Form 3 Satisfaction Questionnaire	Form and Instruction	New	Available
Form 2 Debriefing Questions	Form and Instruction	New	Available
Form 1 Demographics Questionnaire	Form and Instruction	New	Available
Form 2 Follow Up Questions	Form	New	Available
Form 1 Paper Survey	Form and Instruction	New	Available
Form 1 Questionnaire	Form and Instruction	New	Available
Form 8 Spanish Topical Questionnaire 3	Form and Instruction	New	Available
Form 7 Spanish Topical Questionnaire 2	Form and Instruction	New	Available
Form 6 Spanish Topical Questionnaire 1	Form and Instruction	New	Available
Form 5 Spanish Screener	Form and Instruction	New	Available
Form 4 English Topical Questionnaire 3	Form and Instruction	New	Available
Form 3 English Topical Questionnaire 2	Form and Instruction	New	Available
Form 2 English Topical Questionnaire 1	Form and Instruction	New	Available
Form 1 English Screener	Form and Instruction	New	Available
Form 1 Protocol	Form	New	Available
Form 1 Annual Survey of Businesses Questionnaire	Form and Instruction	New	Available
Form 2 Roster Questions for Group 1	Form and Instruction	New	Available
Form 1 Survey Questions	Form and Instruction	New	Available
Form 3 Roster Questions for Group 2	Form and Instruction	New	Available
Form 3 Usability Satisfaction Questionnaire	Form and Instruction	New	Available
Form 2 Demographics Questionnaire	Form and Instruction	New	Available
Form 1 Paper Questionnaire	Form and Instruction	New	Available
Form 2 Privacy Act Statement	Form and Instruction	New	Available
Form 1 Experimental Info	Form and Instruction	New	Available
Form BE-120 V2 Version 2 Supplement	Form and Instruction	New	Available
Form BE-120 V1 Version 1 Supplement	Form and Instruction	New	Available
Form BE-120 Questionnaire	Form and Instruction	New	Available
Form 1 Full Questionnaire	Form	New	Available
Form 1 Application	Form and Instruction	New	Available
Form 3 Satisfaction Questionnaire	Form	New	Available
Form 2 Computer Use and Internet Experience Questionnaire	Form	New	Available
Form 1 Demographics Questionnaire	Form	New	Available
Form 1 Protocol	Form	New	Available
Form 1 Draft Questions	Form	New	Available
Form 1 Questionnaire	Form and Instruction	New	Available
Form 1 Questionnaire	Form	New	Available
Form 2 Debriefing	Form and Instruction	New	Available
Form 1 Questionnaire	Form and Instruction	New	Available
Form Questionnaire Questionnaire	Form and Instruction	New	Available
Form Screener Screener	Form	New	Available
Form Debriefing Questio Debriefing Question	Form	New	Available
Form Internet and Smart Internet and Smartphone Experience Questions	Form	New	Available
Form Demographic Inform Demographic Information	Form	New	Available
Form CPS CIU Full Quest CPS CIU Full Questionnaire	Form	New	Available
Form CPS CIU Roster Que CPS CIU Roster Questionnaire	Form	New	Available
Form Interviewer-Admini Interviewer-Administered Roster Questions	Form	New	Available
Form Interviewer-Admini Interviewer-Administered Survey Questions	Form	New	Available
Form Paper Survey Quest Paper Survey Questions	Form	New	Available
Form Petroleum Construc Petroleum Construction Natural Gas Questions	Form and Instruction	New	Available
Form MEPS – IC Medical Expenditure Panel Survey – Insurance Component (MEPS-IC)	Form and Instruction	New	Available
Form Web Satisfaction Q Web Satisfaction Questionnaire	Form and Instruction	New	Available
Form Internet Screener Internet Screener	Form and Instruction	New	Available
Form Telephone Recruitm Telephone Recruitment Screener	Form and Instruction	New	Available
omb83-(0607-0725).pdf	Supplementary Document	Uploaded 2016-06-08	Available
KeyElements072015.docx	Supplementary Document	Uploaded 2016-06-07	Available
Attachment A.doc	Supplementary Document	Uploaded 2016-06-07	Available
16genclrpartB (format).doc	Supporting Statement B	Uploaded 2016-06-07	Available
16genclrpartA (format).doc	Supporting Statement A	Uploaded 2016-06-07	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
237219	Annual Retail Trade Survey Cognitive Testing	Form and Instruction	New	Select Survey Items
237067	NSCH Questionnaire Cognitive Interviews	Form and Instruction	New	Cognitive Interview Version 3
237067	NSCH Questionnaire Cognitive Interviews	Form and Instruction	New	Cognitive Interview Version 2
237067	NSCH Questionnaire Cognitive Interviews	Form and Instruction	New	Cognitive Interview Version 1
237067	NSCH Questionnaire Cognitive Interviews	Form and Instruction	New	Screener Survey
236843	NSCH Mail Materials Cognitive Testing	Form and Instruction	New	Mail Materials
236827	2020 Privacy & Confidentiality Cognitive Testing	Form and Instruction	New	Online Questionnaire w/o citizenship
236827	2020 Privacy & Confidentiality Cognitive Testing	Form and Instruction	New	Online Questionnaire w/ citizenship
236827	2020 Privacy & Confidentiality Cognitive Testing	Form and Instruction	New	2020 Census Follow Up Survey w/o citizenship
236827	2020 Privacy & Confidentiality Cognitive Testing	Form and Instruction	New	2020 Census Follow Up Survey w/ citizenship
236827	2020 Privacy & Confidentiality Cognitive Testing	Form and Instruction	New	2020 Census Draft w/o citizenship
236827	2020 Privacy & Confidentiality Cognitive Testing	Form and Instruction	New	2020 Census Draft w/ citizenship
236635	Early Stage Scoping for the Commodity Flow Survey	Form and Instruction	New	2017 CFS Instrument
236519	NSP Usability Testing	Form and Instruction	New	Satisfaction Questionnaire
236519	NSP Usability Testing	Form and Instruction	New	Mobile Experience Questionnaire
236519	NSP Usability Testing	Form and Instruction	New	Demographic Questionnaire
236519	NSP Usability Testing	Form and Instruction	New	Paper Questionnaire
236519	NSP Usability Testing	Form and Instruction	New	Log On Letter
236517	Econ Record Keep Study	Form and Instruction	New	Example Survey Questions
236517	Econ Record Keep Study	Form and Instruction	New	Example Chart
236498	2020 CPEX Extending the Census Environment Cog Testing	Form and Instruction	New	Mailing Materials
236399	2019 ABS Globalization Module Cognitive Testing	Form and Instruction	New	Globalization Module draft
236358	NYCHVS Cognitive Interviews	Form and Instruction	New	Flash Cards
236358	NYCHVS Cognitive Interviews	Form and Instruction	New	Protocol V2 (Renter)
236358	NYCHVS Cognitive Interviews	Form and Instruction	New	Protocol V1 (Owner)
236294	ASM Robotics Debriefings	Form and Instruction	New	Robotics Questions
236084	CPS Food Security Supplement	Form and Instruction	New	Protocol and Questionnaire
236008	2019 ABS Innovation Module Cognitive Testing	Form and Instruction	New	Tech Capabilities List
236008	2019 ABS Innovation Module Cognitive Testing	Form and Instruction	New	Digital Tech Cards
236008	2019 ABS Innovation Module Cognitive Testing	Form and Instruction	New	Business Strategies Handout
236008	2019 ABS Innovation Module Cognitive Testing	Form and Instruction	New	Barriers and Drivers Handout
236008	2019 ABS Innovation Module Cognitive Testing	Form and Instruction	New	Innovation Handout
236008	2019 ABS Innovation Module Cognitive Testing	Form and Instruction	New	Revised Innovation Module
235998	CEDSCI Usability Evaluation Addendum	Form	New	Satisfaction Questionnaire
235998	CEDSCI Usability Evaluation Addendum	Form	New	Debriefing Questionnaire
235998	CEDSCI Usability Evaluation Addendum	Form	New	Internet Use Questionnaire
235998	CEDSCI Usability Evaluation Addendum	Form	New	Demographics Questionnaire
235997	ACES Machine Learning Debriefings	Form and Instruction	New	Screenshots of Instrument
235431	UYC Cog Testing and Focus Groups	Form and Instruction	New	Cognitive Interviewing Protocol
235431	UYC Cog Testing and Focus Groups	Form and Instruction	New	Focus Group Protocol
235377	MEPS Cognitive Testing	Form and Instruction	New	Form MEPS 11s
235377	MEPS Cognitive Testing	Form and Instruction	New	Form MEPS 11
235377	MEPS Cognitive Testing	Form and Instruction	New	Form MEPS 10s
235377	MEPS Cognitive Testing	Form and Instruction	New	Form MEPS 10
235084	Vacant Crowdsourcing Internet Study	Form and Instruction	New	Preference of Address Display Question
235084	Vacant Crowdsourcing Internet Study	Form and Instruction	New	Satisfaction with Instrument Questionnaire
235084	Vacant Crowdsourcing Internet Study	Form and Instruction	New	Version 6 of Address Display
235084	Vacant Crowdsourcing Internet Study	Form and Instruction	New	Version 5 of Address Display
235084	Vacant Crowdsourcing Internet Study	Form and Instruction	New	Version 4 of Address Display
235084	Vacant Crowdsourcing Internet Study	Form and Instruction	New	Version 3 of Address Display
235084	Vacant Crowdsourcing Internet Study	Form and Instruction	New	Version 2 of Address Display
235084	Vacant Crowdsourcing Internet Study	Form and Instruction	New	Version 1 of Address Display
235084	Vacant Crowdsourcing Internet Study	Form and Instruction	New	Mailing Materials
234975	2020 Tracking Survey	Form and Instruction	New	Web Probe Testing - Screencaps of Web Testing
234975	2020 Tracking Survey	Form and Instruction	New	Web Probe Testing - Screencap of Introduction to Web Survey
234975	2020 Tracking Survey	Form and Instruction	New	Cog Testing - Demographics Questionnaire
234975	2020 Tracking Survey	Form and Instruction	New	Cog Testing - Web Form of Census Tracking Questionnaire
234975	2020 Tracking Survey	Form and Instruction	New	Cog Testing - Census Tracking Questionnaire
234975	2020 Tracking Survey	Form and Instruction	New	Web Probe Testing - Language Questions for Web
234858	2020 Census Vacant Unit Crowdsourcing Research	Form and Instruction	New	Online Instrument
234726	2019 ACS POW-HOA Cognitive Testing to Reduce Burden	Form and Instruction	New	Modified ACS Paper Form
234426	2019 SAS Telemedicine Cog Interviews	Form	New	Attachment C - SAS Questionnaire
234426	2019 SAS Telemedicine Cog Interviews	Form	New	Attachment A - Proposed Telemedicine Questions for SAS
234062	National Survey of Psychiatrists Cognitive Testing	Form and Instruction	New	Alternative Cover Image 2
234062	National Survey of Psychiatrists Cognitive Testing	Form and Instruction	New	Alternative Cover Image 1
234062	National Survey of Psychiatrists Cognitive Testing	Form and Instruction	New	Alternative Full page Coversheet w/ Questionnaire (beginning)
234062	National Survey of Psychiatrists Cognitive Testing	Form and Instruction	New	Questionnaire
233847	2019 Generic Screener with UYC Pilot Screener	Form	New	Screeners part A and part B
233636	Quarterly Survey of Public Pensions Cognitive Testing	Form and Instruction	New	QSPP Draft Questionnaire
233477	NSCH Screener Cognitive Interviews	Form and Instruction	New	Perforated Mockup 2
233477	NSCH Screener Cognitive Interviews	Form and Instruction	New	Perforated Mockup 1
233477	NSCH Screener Cognitive Interviews	Form and Instruction	New	NonPerforated Mockup 2
233477	NSCH Screener Cognitive Interviews	Form and Instruction	New	NonPerforated Mockup 1
233477	NSCH Screener Cognitive Interviews	Form and Instruction	New	Standard Treatments A and D
233477	NSCH Screener Cognitive Interviews	Form and Instruction	New	Experimental Treatment C
233477	NSCH Screener Cognitive Interviews	Form and Instruction	New	Experimental Treatment B - Perforated Mockup 2
233477	NSCH Screener Cognitive Interviews	Form and Instruction	New	Experimental Treatment B - Perforated Mockup 1
233477	NSCH Screener Cognitive Interviews	Form and Instruction	New	Experimental Treatment B - NonPerforated Mockup 2
233477	NSCH Screener Cognitive Interviews	Form and Instruction	New	Experimental Treatment B - NonPerforated Mockup 1
233477	NSCH Screener Cognitive Interviews	Form and Instruction	New	Screener Card
233079	SAS E-Commerce Respondent Debriefings	Form	New	E-Commerce Questions
233077	ABS Telephone Respondent Debriefings	Form and Instruction	New	2017 ABS Questionnaire
232899	NAPCS Debriefings	Form and Instruction	New	NAPCS Instrument Screens
232672	MEPS Telephone Interviews	Form and Instruction	New	2017 MEPS-10S Form
232672	MEPS Telephone Interviews	Form and Instruction	New	2017 MEPS-10 Form
232672	MEPS Telephone Interviews	Form and Instruction	New	2018 MEPS-10S Form
232672	MEPS Telephone Interviews	Form and Instruction	New	2018 MEPS-10 Form
232518	Addendum for IOE Mobile UI Project Phase 2	Form and Instruction	New	Test materials as seen by respondents
232233	2018 ABS Technology Module Cog Testing	Form and Instruction	New	Attachment D - Technology Module Questionnaire
232233	2018 ABS Technology Module Cog Testing	Form and Instruction	New	ABS R and D Questionnaire
232233	2018 ABS Technology Module Cog Testing	Form and Instruction	New	ABS Questionnaire
231993	2020 Respondent Privacy Cognitive Interviews Round 2	Form and Instruction	New	Privacy and Confidentiality Questionnaire
231985	BRDS Cognitive Testing	Form and Instruction	New	Leased / Temporary Employees Questionnaire
231985	BRDS Cognitive Testing	Form and Instruction	New	Aritificial Intelligence Questionnaire
231933	2019 AHS Housing Insecurity Cognitive Testing	Form and Instruction	New	Protocol and Questionnaire
231703	ACS Respondent Comment/Feedback Addendum	Form and Instruction	New	ACS Respondent Feedback items at end of ACS Questionnaire
231703	ACS Respondent Comment/Feedback Addendum	Form and Instruction	New	Entire ACS Questionnaire
231625	2018 Census Test GQE eResponse Debriefings	Form and Instruction	New	eResponse User Manual
231625	2018 Census Test GQE eResponse Debriefings	Form and Instruction	New	Invitation Letter
231625	2018 Census Test GQE eResponse Debriefings	Form and Instruction	New	eResponse Reporting Template
231625	2018 Census Test GQE eResponse Debriefings	Form and Instruction	New	2018 GQE eResponse Site
231522	Business Unit Harmonization Phase 3	Form and Instruction	New	BUH MockUp
231455	FGP Econ Census Respondent Debriefings	Form	New	FGP Questions from Econ Census
231218	Census Test Usability Testing Addendum	Form and Instruction	New	Satisfaction Questionnaire
231218	Census Test Usability Testing Addendum	Form and Instruction	New	Mobile Experience Questionnaire
231218	Census Test Usability Testing Addendum	Form and Instruction	New	Demographics Questionnaire
231218	Census Test Usability Testing Addendum	Instruction	New
231218	Census Test Usability Testing Addendum	Form and Instruction	New	Instrument Debriefing Screens
231191	2018 ACS Respondent Burden Testing	Form and Instruction	New	ACS Questionnaire From Q29 V2
231191	2018 ACS Respondent Burden Testing	Form and Instruction	New	ACS Questionnaire From Q29 V1
231191	2018 ACS Respondent Burden Testing	Form and Instruction	New	ACS Questionnaire Up to Q28
231154	2018 MOPS Hospitals	Form and Instruction	New	Questionnaire
231153	ACES Robotics	Form and Instruction	New	Question
230846	2017 Economic Census Debriefings	Form and Instruction	New	Econ Census Web Screens
230569	CEDSCI Usability Addendum	Form	New	Satisfaction Questionnaire
230569	CEDSCI Usability Addendum	Form	New	Debriefing Questionnaire
230569	CEDSCI Usability Addendum	Form	New	Internet Experience Questionnaire
230569	CEDSCI Usability Addendum	Form	New	Demographic Questionnaire
230478	2017 ABS Usability Testing	Form	New	Instrument screenshots
230292	2019 AHS Cognitive Testing	Form and Instruction	New	Protocol and Questionnaire
230290	2018 NSCH Usability Evaluation	Form and Instruction	New	Satisfaction Questionnaire
230290	2018 NSCH Usability Evaluation	Form and Instruction	New	Demographic Questionnaire
230290	2018 NSCH Usability Evaluation	Form and Instruction	New	Questionnaire V4
230290	2018 NSCH Usability Evaluation	Form and Instruction	New	Questionnaire V3
230290	2018 NSCH Usability Evaluation	Form and Instruction	New	Questionnaire V2
230290	2018 NSCH Usability Evaluation	Form and Instruction	New	Questionnaire V1
230041	2018 BRDIS Cognitive Testing	Form and Instruction	New	Consent Form
230041	2018 BRDIS Cognitive Testing	Form and Instruction	New	Capitol Stock Questions
230041	2018 BRDIS Cognitive Testing	Form and Instruction	New	BRDIS 2016
230041	2018 BRDIS Cognitive Testing	Form and Instruction	New	Geography Questions
229783	American Community Survey (ACS) Respondent Comment/Feedback	Form	New	Comment and Feedback Question
229783	American Community Survey (ACS) Respondent Comment/Feedback	Instruction	New
229783	American Community Survey (ACS) Respondent Comment/Feedback	Form	New	2017 ACS form
228752	2020 CBAMS Addendum	Form and Instruction	New	Internet and Mobile Experience Questionnaire
228752	2020 CBAMS Addendum	Form and Instruction	New	Demographic Questionnaire
228748	2018 Centurion Site Tutorial Videos Cog Testing	Form and Instruction	New	Video Satisfaction Questionnare
228748	2018 Centurion Site Tutorial Videos Cog Testing	Form	New	Usability Tasks
228748	2018 Centurion Site Tutorial Videos Cog Testing	Form	New	Video Screenshots
228701	Cognitive Testing of Privacy Act Language	Form and Instruction	New	Confidentiality Statements in English
228701	Cognitive Testing of Privacy Act Language	Form and Instruction	New	Privacy Act Test Language and FAQ Context
228585	MEPS–IC Cog Testing	Form and Instruction	New	MEPS-11S
228585	MEPS–IC Cog Testing	Form and Instruction	New	MEPS-11
228585	MEPS–IC Cog Testing	Form and Instruction	New	MEPS-10S
228585	MEPS–IC Cog Testing	Form and Instruction	New	MEPS-10
228429	ASM Robotics	Form and Instruction	New	Version D Questions
228429	ASM Robotics	Form and Instruction	New	Version C Questions
228429	ASM Robotics	Form and Instruction	New	Version B Questions
228429	ASM Robotics	Form and Instruction	New	Version A Questions
227924	BRDI-M Respondent Debriefings	Form and Instruction	New	Protocol
227899	2020 Respondent Privacy Cognitive Interviews	Form and Instruction	New	Privacy Concerns Questionnaire
227896	NSSRN Usability Evaluation	Form and Instruction	New	NSSRN Questionnaire
227896	NSSRN Usability Evaluation	Form and Instruction	New	Satisfaction Questionnaire
227896	NSSRN Usability Evaluation	Form and Instruction	New	Debriefing Questions
227896	NSSRN Usability Evaluation	Form and Instruction	New	Demographics Questionnaire
227780	ACS Respondent Perceptions of Burden	Form	New	Follow Up Questions
227780	ACS Respondent Perceptions of Burden	Form and Instruction	New	Paper Survey
227726	2017 PRA Testing	Instruction	New
227425	CFS Debriefing Study	Form and Instruction	New	Questionnaire
227344	NSCH Questionnaire Cognitive Testing	Form and Instruction	New	Spanish Topical Questionnaire 3
227344	NSCH Questionnaire Cognitive Testing	Form and Instruction	New	Spanish Topical Questionnaire 2
227344	NSCH Questionnaire Cognitive Testing	Form and Instruction	New	Spanish Topical Questionnaire 1
227344	NSCH Questionnaire Cognitive Testing	Form and Instruction	New	Spanish Screener
227344	NSCH Questionnaire Cognitive Testing	Form and Instruction	New	English Topical Questionnaire 3
227344	NSCH Questionnaire Cognitive Testing	Form and Instruction	New	English Topical Questionnaire 2
227344	NSCH Questionnaire Cognitive Testing	Form and Instruction	New	English Topical Questionnaire 1
227344	NSCH Questionnaire Cognitive Testing	Form and Instruction	New	English Screener
227236	Business Unit Harmonization Project Case Studies Addendum	Form	New	Protocol
227178	2017 Annual Survey of Businesses Cog Testing	Form and Instruction	New	Annual Survey of Businesses Questionnaire
227164	ACS Respondent Burden Cognitive Testing	Form and Instruction	New	Roster Questions for Group 1
227164	ACS Respondent Burden Cognitive Testing	Form and Instruction	New	Survey Questions
227164	ACS Respondent Burden Cognitive Testing	Form and Instruction	New	Roster Questions for Group 2
226990	CBAMS Cognitive and Usability Interviews	Form and Instruction	New	Usability Satisfaction Questionnaire
226990	CBAMS Cognitive and Usability Interviews	Form and Instruction	New	Demographics Questionnaire
226990	CBAMS Cognitive and Usability Interviews	Form and Instruction	New	Paper Questionnaire
226988	Mobile UI Design Framework for Survey Operations – Phase 1, Study 2	Form and Instruction	New	Privacy Act Statement
226988	Mobile UI Design Framework for Survey Operations – Phase 1, Study 2	Form and Instruction	New	Experimental Info
226951	BE-120 Cognitive Interviews	Form and Instruction	New	Version 2 Supplement
226951	BE-120 Cognitive Interviews	Form and Instruction	New	Version 1 Supplement
226951	BE-120 Cognitive Interviews	Form and Instruction	New	Questionnaire
226802	2018 NCVS PPCS Cognitive Interviews	Form	New	Full Questionnaire
226491	2017 NCVS Mail Materials Project	Instruction	New
226079	2017 FNS Usability Testing	Form and Instruction	New	Application
225780	2017 Economic Census Usability Testing and Debriefs	Form	New	Satisfaction Questionnaire
225780	2017 Economic Census Usability Testing and Debriefs	Form	New	Computer Use and Internet Experience Questionnaire
225780	2017 Economic Census Usability Testing and Debriefs	Form	New	Demographics Questionnaire
225625	Business Unit Harmonization Project Case Studies	Form	New	Protocol
225543	2017 SAS Cognitive Interviews	Form	New	Draft Questions
224969	BE-125 Respondent Debriefings	Form and Instruction	New	Questionnaire
224930	ASPP Cognitive Interviews	Form	New	Questionnaire
224845	NAPCS Questionnaire Field Test	Form and Instruction	New	Debriefing
224845	NAPCS Questionnaire Field Test	Form and Instruction	New	Questionnaire
224813	NSSRN Cognitive Testing	Form and Instruction	New	Questionnaire
224813	NSSRN Cognitive Testing	Form	New	Screener
224374	CEDSCI Usability Evaluation	Form	New	Debriefing Question
224374	CEDSCI Usability Evaluation	Form	New	Internet and Smartphone Experience Questions
224374	CEDSCI Usability Evaluation	Form	New	Demographic Information
224275	Current Population Survey Computer and Internet Use (CPS CIU) Supplemental Test	Form	New	CPS CIU Full Questionnaire
224275	Current Population Survey Computer and Internet Use (CPS CIU) Supplemental Test	Form	New	CPS CIU Roster Questionnaire
224169	2017 American Community Survey Respondent Burden Testing	Form	New	Interviewer-Administered Roster Questions
224169	2017 American Community Survey Respondent Burden Testing	Form	New	Interviewer-Administered Survey Questions
224169	2017 American Community Survey Respondent Burden Testing	Form	New	Paper Survey Questions
223989	2017 Economic Census New Question Testing Addendum	Form and Instruction	New	Petroleum Construction Natural Gas Questions
223608	Pretest Medical Expenditure Panel Survey – Insurance Component (MEPS-IC)	Form and Instruction	New	Medical Expenditure Panel Survey – Insurance Component (MEPS-IC)
222450	Web Satisfaction Questionnaire Development	Form and Instruction	New	Web Satisfaction Questionnaire
221822	Recruitment Screener	Form and Instruction	New	Internet Screener
221822	Recruitment Screener	Form and Instruction	New	Telephone Recruitment Screener

ICR Details

OMB Control No: 0607-0725	ICR Reference No: 201606-0607-003
Status: Historical Active	Previous ICR Reference No: 201312-0607-004
Agency/Subagency: DOC/CENSUS	Agency Tracking No:
Title: Generic Clearance for Questionnaire Pretesting Research
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 09/09/2016
Retrieve Notice of Action (NOA)	Date Received in OIRA: 07/28/2016
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2019	36 Months From Approved	09/30/2016
Responses	16,500	0	16,500
Time Burden (Hours)	16,500	0	16,500
Cost Burden (Dollars)	0	0	0

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Abstract: The research will be used by the Census Bureau and the survey sponsors to improve questionnaires and procedures, reduce respondent burden, and ultimately increase the quality of data collected in Census Bureau censuses and surveys.

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Authorizing Statute(s): US Code: 13 USC 131, 141, 161, 181, 182, 193,
  

Citations for New Statutory Requirements: None

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

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 28929	11/13/2015
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 32720	05/24/2016
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 85

table that charts list of burden

IC Title	Form No.	Form Name
2017 ABS Usability Testing	1	Instrument screenshots
2017 American Community Survey Respondent Burden Testing	Interviewer-Administered Survey Questions, Paper Survey Questions, Interviewer-Administered Roster Questions	Paper Survey Questions ,   Interviewer-Administered Survey Questions ,   Interviewer-Administered Roster Questions
2017 Annual Survey of Businesses Cog Testing	1	Annual Survey of Businesses Questionnaire
2017 Economic Census Debriefings	1	Econ Census Web Screens
2017 Economic Census New Question Testing Addendum	Petroleum Construction Natural Gas Questions	Petroleum Construction Natural Gas Questions
2017 Economic Census Usability Testing and Debriefs	1, 2, 3	Demographics Questionnaire ,   Computer Use and Internet Experience Questionnaire ,   Satisfaction Questionnaire
2017 FNS Usability Testing	1	Application
2017 NCVS Mail Materials Project
2017 PRA Testing
2017 SAS Cognitive Interviews	1	Draft Questions
2018 ABS Technology Module Cog Testing	3, 1, 2	ABS Questionnaire ,   ABS R and D Questionnaire ,   Attachment D - Technology Module Questionnaire
2018 ACS Respondent Burden Testing	1, 3, 2	ACS Questionnaire Up to Q28 ,   ACS Questionnaire From Q29 V1 ,   ACS Questionnaire From Q29 V2
2018 BRDIS Cognitive Testing	4, 2, 3, 1	BRDIS 2016 ,   Geography Questions ,   Capitol Stock Questions ,   Consent Form
2018 Census Test GQE eResponse Debriefings	3, 1, 2, 4	2018 GQE eResponse Site ,   eResponse Reporting Template ,   Invitation Letter ,   eResponse User Manual
2018 Centurion Site Tutorial Videos Cog Testing	2, 1, 3	Video Screenshots ,   Usability Tasks ,   Video Satisfaction Questionnare
2018 MOPS Hospitals	1	Questionnaire
2018 NCVS PPCS Cognitive Interviews	1	Full Questionnaire
2018 NSCH Usability Evaluation	4, 5, 1, 2, 3, 6	Questionnaire V1 ,   Questionnaire V2 ,   Questionnaire V3 ,   Questionnaire V4 ,   Demographic Questionnaire ,   Satisfaction Questionnaire
2019 ABS Globalization Module Cognitive Testing	1	Globalization Module draft
2019 ABS Innovation Module Cognitive Testing	1, 2, 3, 4, 5, 6	Revised Innovation Module ,   Innovation Handout ,   Barriers and Drivers Handout ,   Business Strategies Handout ,   Digital Tech Cards ,   Tech Capabilities List
2019 ACS POW-HOA Cognitive Testing to Reduce Burden	1	Modified ACS Paper Form
2019 AHS Cognitive Testing	1	Protocol and Questionnaire
2019 AHS Housing Insecurity Cognitive Testing	1	Protocol and Questionnaire
2019 Generic Screener with UYC Pilot Screener	1	Screeners part A and part B
2019 SAS Telemedicine Cog Interviews	1, 2	Attachment A - Proposed Telemedicine Questions for SAS ,   Attachment C - SAS Questionnaire
2020 CBAMS Addendum	2, 1	Demographic Questionnaire ,   Internet and Mobile Experience Questionnaire
2020 CPEX Extending the Census Environment Cog Testing	1	Mailing Materials
2020 Census Vacant Unit Crowdsourcing Research	1	Online Instrument
2020 Privacy & Confidentiality Cognitive Testing	6, 1, 2, 3, 4, 5	2020 Census Draft w/ citizenship ,   2020 Census Draft w/o citizenship ,   2020 Census Follow Up Survey w/ citizenship ,   2020 Census Follow Up Survey w/o citizenship ,   Online Questionnaire w/ citizenship ,   Online Questionnaire w/o citizenship
2020 Respondent Privacy Cognitive Interviews	1	Privacy Concerns Questionnaire
2020 Respondent Privacy Cognitive Interviews Round 2	1	Privacy and Confidentiality Questionnaire
2020 Tracking Survey	3, 1, 2, 4, 5, 6	Cog Testing - Census Tracking Questionnaire ,   Cog Testing - Web Form of Census Tracking Questionnaire ,   Cog Testing - Demographics Questionnaire ,   Web Probe Testing - Language Questions for Web ,   Web Probe Testing - Screencap of Introduction to Web Survey ,   Web Probe Testing - Screencaps of Web Testing
ABS Telephone Respondent Debriefings	1	2017 ABS Questionnaire
ACES Machine Learning Debriefings	1	Screenshots of Instrument
ACES Robotics	1	Question
ACS Respondent Burden Cognitive Testing	1, 2, 3	Survey Questions ,   Roster Questions for Group 1 ,   Roster Questions for Group 2
ACS Respondent Comment/Feedback Addendum	1, 2	Entire ACS Questionnaire ,   ACS Respondent Feedback items at end of ACS Questionnaire
ACS Respondent Perceptions of Burden	2, 1	Paper Survey ,   Follow Up Questions
ASM Robotics	1, 3, 4, 2	Version A Questions ,   Version B Questions ,   Version C Questions ,   Version D Questions
ASM Robotics Debriefings	1	Robotics Questions
ASPP Cognitive Interviews	1	Questionnaire
Addendum for IOE Mobile UI Project Phase 2	1	Test materials as seen by respondents
American Community Survey (ACS) Respondent Comment/Feedback	2017 ACS form, Comment and Feedback Question	2017 ACS form ,   Comment and Feedback Question
Annual Retail Trade Survey Cognitive Testing	1	Select Survey Items
BE-120 Cognitive Interviews	BE-120 V1, BE-120 V2, BE-120	Questionnaire ,   Version 1 Supplement ,   Version 2 Supplement
BE-125 Respondent Debriefings	1	Questionnaire
BRDI-M Respondent Debriefings	1	Protocol
BRDS Cognitive Testing	2, 1	Aritificial Intelligence Questionnaire ,   Leased / Temporary Employees Questionnaire
Business Unit Harmonization Phase 3	1	BUH MockUp
Business Unit Harmonization Project Case Studies	1	Protocol
Business Unit Harmonization Project Case Studies Addendum	1	Protocol
CBAMS Cognitive and Usability Interviews	2, 1, 3	Paper Questionnaire ,   Demographics Questionnaire ,   Usability Satisfaction Questionnaire
CEDSCI Usability Addendum	1, 2, 3, 4	Demographic Questionnaire ,   Internet Experience Questionnaire ,   Debriefing Questionnaire ,   Satisfaction Questionnaire
CEDSCI Usability Evaluation	Demographic Information, Debriefing Question, Internet and Smartphone Experience Questions	Demographic Information ,   Internet and Smartphone Experience Questions ,   Debriefing Question
CEDSCI Usability Evaluation Addendum	4, 3, 1, 2	Demographics Questionnaire ,   Internet Use Questionnaire ,   Debriefing Questionnaire ,   Satisfaction Questionnaire
CFS Debriefing Study	1	Questionnaire
CPS Food Security Supplement	1	Protocol and Questionnaire
Census Test Usability Testing Addendum	2, 1, 3, 4	Instrument Debriefing Screens ,   Demographics Questionnaire ,   Mobile Experience Questionnaire ,   Satisfaction Questionnaire
Cognitive Testing of Privacy Act Language	1, 2	Privacy Act Test Language and FAQ Context ,   Confidentiality Statements in English
Current Population Survey Computer and Internet Use (CPS CIU) Supplemental Test	CPS CIU Roster Questionnaire, CPS CIU Full Questionnaire	CPS CIU Roster Questionnaire ,   CPS CIU Full Questionnaire
Early Stage Scoping for the Commodity Flow Survey	1	2017 CFS Instrument
Econ Record Keep Study	1, 2	Example Chart ,   Example Survey Questions
FGP Econ Census Respondent Debriefings	1	FGP Questions from Econ Census
MEPS Cognitive Testing	4, 3, 1, 2	Form MEPS 10 ,   Form MEPS 10s ,   Form MEPS 11 ,   Form MEPS 11s
MEPS Telephone Interviews	1, 3, 4, 2	2018 MEPS-10 Form ,   2018 MEPS-10S Form ,   2017 MEPS-10 Form ,   2017 MEPS-10S Form
MEPS–IC Cog Testing	4, 1, 2, 3	MEPS-10 ,   MEPS-10S ,   MEPS-11 ,   MEPS-11S
Mobile UI Design Framework for Survey Operations – Phase 1, Study 2	1, 2	Experimental Info ,   Privacy Act Statement
NAPCS Debriefings	1	NAPCS Instrument Screens
NAPCS Questionnaire Field Test	2, 1	Questionnaire ,   Debriefing
NSCH Mail Materials Cognitive Testing	1	Mail Materials
NSCH Questionnaire Cognitive Interviews	4, 3, 2, 1	Screener Survey ,   Cognitive Interview Version 1 ,   Cognitive Interview Version 2 ,   Cognitive Interview Version 3
NSCH Questionnaire Cognitive Testing	3, 4, 6, 7, 8, 1, 2, 5	English Screener ,   English Topical Questionnaire 1 ,   English Topical Questionnaire 2 ,   English Topical Questionnaire 3 ,   Spanish Screener ,   Spanish Topical Questionnaire 1 ,   Spanish Topical Questionnaire 2 ,   Spanish Topical Questionnaire 3
NSCH Screener Cognitive Interviews	1, 4, 8, 11, 2, 3, 5, 6, 7, 9, 10	Screener Card ,   Experimental Treatment B - NonPerforated Mockup 1 ,   Experimental Treatment B - NonPerforated Mockup 2 ,   Experimental Treatment B - Perforated Mockup 1 ,   Experimental Treatment B - Perforated Mockup 2 ,   Experimental Treatment C ,   Standard Treatments A and D ,   NonPerforated Mockup 1 ,   NonPerforated Mockup 2 ,   Perforated Mockup 1 ,   Perforated Mockup 2
NSP Usability Testing	1, 2, 3, 4, 5	Log On Letter ,   Paper Questionnaire ,   Demographic Questionnaire ,   Mobile Experience Questionnaire ,   Satisfaction Questionnaire
NSSRN Cognitive Testing	Questionnaire, Screener	Questionnaire ,   Screener
NSSRN Usability Evaluation	2, 3, 4, 1	Demographics Questionnaire ,   Debriefing Questions ,   Satisfaction Questionnaire ,   NSSRN Questionnaire
NYCHVS Cognitive Interviews	3, 2, 1	Protocol V1 (Owner) ,   Protocol V2 (Renter) ,   Flash Cards
National Survey of Psychiatrists Cognitive Testing	1, 2, 4, 3	Questionnaire ,   Alternative Full page Coversheet w/ Questionnaire (beginning) ,   Alternative Cover Image 1 ,   Alternative Cover Image 2
Pretest Medical Expenditure Panel Survey – Insurance Component (MEPS-IC)	MEPS – IC	Medical Expenditure Panel Survey – Insurance Component (MEPS-IC)
Quarterly Survey of Public Pensions Cognitive Testing	1	QSPP Draft Questionnaire
Recruitment Screener	Internet Screener, Telephone Recruitment Screener	Telephone Recruitment Screener ,   Internet Screener
SAS E-Commerce Respondent Debriefings	1	E-Commerce Questions
UYC Cog Testing and Focus Groups	1, 2	Focus Group Protocol ,   Cognitive Interviewing Protocol
Vacant Crowdsourcing Internet Study	5, 6, 9, 7, 1, 2, 4, 3, 8	Mailing Materials ,   Version 1 of Address Display ,   Version 2 of Address Display ,   Version 3 of Address Display ,   Version 4 of Address Display ,   Version 5 of Address Display ,   Version 6 of Address Display ,   Satisfaction with Instrument Questionnaire ,   Preference of Address Display Question
Web Satisfaction Questionnaire Development	Web Satisfaction Questionnaire	Web Satisfaction Questionnaire

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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	16,500	16,500	0	0	0	0
Annual Time Burden (Hours)	16,500	16,500	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $0

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]? No

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

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Common Form ICR:  No

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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: 07/28/2016

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