NSCH Questionnaire Cognitive Testing

Generic Clearance for Questionnaire Pretesting Research

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

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

Information Collection (IC) Details

IC Title:	NSCH Questionnaire Cognitive Testing	Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection 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 %

	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

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.