2019 AHS 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⚠️ Notice: This information collection may be referencing outdated material.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 2019 AHS Cognitive Testing Form and Instructi
1 Protocol and Questionnaire AHS 2019 Protocol_Round 1_FINAL_03272018_clean.docx Form and Instruction
Enclosure 2 - 2019 AHS Screener_02282018.docx Recruitment Screener IC Document
Enclosure 4 - Consent Form_AHS 2019_ 02282018.docx Consent Form IC Document
Enclosure 3a - AHS Recruiting Ads_BOC Email and Craigslist_02282018.pdf Recruitment Ads IC Document
Enclosure 3b - AHS Recruiting Ad_Flyer_02282018.pdf Recruitment Flyer IC Document
OMB Memo_AHS_FINAL_02282018.docx OMB Memo IC Document

Information Collection (IC) Details

IC Title:	2019 AHS 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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	1	Protocol and Questionnaire	AHS 2019 Protocol_Round 1_FINAL_03272018_clean.docx		No		Fillable Fileable

Line of Business: General Government

Subfunction: Central Records & Statistical Mgt

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 35	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	35	35
Annual IC Time Burden (Hours)	53	53
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Recruitment Screener	Enclosure 2 - 2019 AHS Screener_02282018.docx	03/01/2018
Consent Form	Enclosure 4 - Consent Form_AHS 2019_ 02282018.docx	03/01/2018
Recruitment Ads	Enclosure 3a - AHS Recruiting Ads_BOC Email and Craigslist_02282018.pdf	03/01/2018
Recruitment Flyer	Enclosure 3b - AHS Recruiting Ad_Flyer_02282018.pdf	03/01/2018
OMB Memo	OMB Memo_AHS_FINAL_02282018.docx	03/22/2018

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