Information Collection

NSCH Screener Cognitive Interviews

IC 233477 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⚠️ Notice: This information collection may be referencing outdated material.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 Screener Cognitive Interviews	Form and Instructi
1 Screener Card Screener Card Content - 2 options_OMB.docx	Form and Instruction
2 Experimental Treatment B - NonPerforated Mockup 1 NSCH11wa - Experimental Treatment B_Non-perforated Mockup 1_OMB.docx	Form and Instruction
3 Experimental Treatment B - NonPerforated Mockup 2 NSCH11wa - Experimental Treatment B_Non-perforated Mockup 2_OMB.docx	Form and Instruction
4 Experimental Treatment B - Perforated Mockup 1 NSCH11wa - Experimental Treatment B_Perforated Mockup 1_OMB.docx	Form and Instruction
5 Experimental Treatment B - Perforated Mockup 2 NSCH11wa - Experimental Treatment B_Perforated Mockup 2_OMB.docx	Form and Instruction
6 Experimental Treatment C NSCH11wa - Experimental Treatment C_OMB.docx	Form and Instruction
7 Standard Treatments A and D NSCH11wa - Standard Version (Treatments A and D)_OMB.docx	Form and Instruction
8 NonPerforated Mockup 1 NSCH12wa - Non-perforated Mockup 1_OMB.docx	Form and Instruction
9 NonPerforated Mockup 2 NSCH12wa - Non-perforated Mockup 2_OMB.docx	Form and Instruction
10 Perforated Mockup 1 NSCH12wa - Perforated Mockup 1_OMB.docx	Form and Instruction
11 Perforated Mockup 2 NSCH12wa - Perforated Mockup 2_OMB.docx	Form and Instruction
OMB letter - NSCH Screener cognitive interviewing_OMB (2).docx OMB Memo	IC Document
NSCH Screener Cognitive Interviewing Protocol _OMB.docx Protocol	IC Document
Participant Screener_NSCH Screener Card_OMB (2).docx Screener	IC Document
NSCH Screener Consent Form_OMB.doc Consent Form	IC Document
NSCH Screener Voucher_OMB.docx Voucher	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

NSCH Screener Cognitive Interviews

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	Screener Card	Screener Card Content - 2 options_OMB.docx	No	Fillable Fileable
Form and Instruction	2	Experimental Treatment B - NonPerforated Mockup 1	NSCH11wa - Experimental Treatment B_Non-perforated Mockup 1_OMB.docx	No	Fillable Fileable
Form and Instruction	3	Experimental Treatment B - NonPerforated Mockup 2	NSCH11wa - Experimental Treatment B_Non-perforated Mockup 2_OMB.docx	No	Fillable Fileable
Form and Instruction	4	Experimental Treatment B - Perforated Mockup 1	NSCH11wa - Experimental Treatment B_Perforated Mockup 1_OMB.docx	No	Fillable Fileable
Form and Instruction	5	Experimental Treatment B - Perforated Mockup 2	NSCH11wa - Experimental Treatment B_Perforated Mockup 2_OMB.docx	No	Fillable Fileable
Form and Instruction	6	Experimental Treatment C	NSCH11wa - Experimental Treatment C_OMB.docx	No	Fillable Fileable
Form and Instruction	7	Standard Treatments A and D	NSCH11wa - Standard Version (Treatments A and D)_OMB.docx	No	Fillable Fileable
Form and Instruction	8	NonPerforated Mockup 1	NSCH12wa - Non-perforated Mockup 1_OMB.docx	No	Fillable Fileable
Form and Instruction	9	NonPerforated Mockup 2	NSCH12wa - Non-perforated Mockup 2_OMB.docx	No	Fillable Fileable
Form and Instruction	10	Perforated Mockup 1	NSCH12wa - Perforated Mockup 1_OMB.docx	No	Fillable Fileable
Form and Instruction	11	Perforated Mockup 2	NSCH12wa - Perforated Mockup 2_OMB.docx	No	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

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
OMB Memo	OMB letter - NSCH Screener cognitive interviewing_OMB (2).docx	10/11/2018
Protocol	NSCH Screener Cognitive Interviewing Protocol _OMB.docx	10/11/2018
Screener	Participant Screener_NSCH Screener Card_OMB (2).docx	10/11/2018
Consent Form	NSCH Screener Consent Form_OMB.doc	10/11/2018
Voucher	NSCH Screener Voucher_OMB.docx	10/11/2018

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