Information Collection

2019 AHS Cognitive Testing

IC 230292 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⚠️ Notice: This information collection may be referencing outdated material.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 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

IC Title:

2019 AHS 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	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 %

table that charts list of burden
	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

table that charts IC Documents
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.