Information Collection

NSCH Questionnaire Cognitive Testing

IC 227344 under ICR 201606-0607-003 · OMB 0607-0725.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0607-0725 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 NSCH Questionnaire Cognitive Testing	Form and Instructi
1 English Screener NSCH S1_Cognitive Interviewing Version.pdf	Form and Instruction
2 English Topical Questionnaire 1 NSCH T1_Cognitive Interviewing Version.pdf	Form and Instruction
3 English Topical Questionnaire 2 NSCH T2_Cognitive Interviewing Version.pdf	Form and Instruction
4 English Topical Questionnaire 3 NSCH T3_Cognitive Interviewing Version.pdf	Form and Instruction
5 Spanish Screener NSCH S1(S)_Cognitive Interviewing Version (2).pdf	Form and Instruction
6 Spanish Topical Questionnaire 1 NSCH T1(S)_Cognitive Interviewing Version (3).pdf	Form and Instruction
7 Spanish Topical Questionnaire 2 NSCH T2(S)_Cognitive Interviewing Version (4).pdf	Form and Instruction
8 Spanish Topical Questionnaire 3 NSCH T3(S)_Cognitive Interviewing Version (1).pdf	Form and Instruction
Screener_NSCH Questionnaire redesign.docx Recruitment Screener	IC Document
Consent forms for Demographic Surveys_NSCH.doc Consent Form	IC Document
voucher_NSCH.docx Voucher Form	IC Document
NSCH Cognitive Interviewing Protocol_OMB.docx Protocol	IC Document
OMB letter - NSCH cognitive interviewing.docx OMB Memo	IC Document

IC Title:

NSCH Questionnaire Cognitive Testing

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.	Form Name	Instrument File	Available Electronically?	Electronic Capability
Form and Instruction	1	English Screener	NSCH S1_Cognitive Interviewing Version.pdf	No	Fillable Fileable
Form and Instruction	2	English Topical Questionnaire 1	NSCH T1_Cognitive Interviewing Version.pdf	No	Fillable Fileable
Form and Instruction	3	English Topical Questionnaire 2	NSCH T2_Cognitive Interviewing Version.pdf	No	Fillable Fileable
Form and Instruction	4	English Topical Questionnaire 3	NSCH T3_Cognitive Interviewing Version.pdf	No	Fillable Fileable
Form and Instruction	5	Spanish Screener	NSCH S1(S)_Cognitive Interviewing Version (2).pdf	No	Fillable Fileable
Form and Instruction	6	Spanish Topical Questionnaire 1	NSCH T1(S)_Cognitive Interviewing Version (3).pdf	No	Fillable Fileable
Form and Instruction	7	Spanish Topical Questionnaire 2	NSCH T2(S)_Cognitive Interviewing Version (4).pdf	No	Fillable Fileable
Form and Instruction	8	Spanish Topical Questionnaire 3	NSCH T3(S)_Cognitive Interviewing Version (1).pdf	No	Fillable Fileable

Line of Business: General Government

Subfunction: Central Records & Statistical Mgt

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 30

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	30	30
Annual IC Time Burden (Hours)	36	36
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Recruitment Screener	Screener_NSCH Questionnaire redesign.docx	06/30/2017
Consent Form	Consent forms for Demographic Surveys_NSCH.doc	06/30/2017
Voucher Form	voucher_NSCH.docx	06/30/2017
Protocol	NSCH Cognitive Interviewing Protocol_OMB.docx	06/30/2017
OMB Memo	OMB letter - NSCH cognitive interviewing.docx	06/30/2017

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