Information Collection

NYCHVS Cognitive Interviews

IC 236358 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⚠️ Notice: This information collection may be referencing outdated material.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 NYCHVS Cognitive Interviews	Form and Instructi
1 Protocol V1 (Owner) Enclosure 1_Owner Protocol_revised.docx	Form and Instruction
2 Protocol V2 (Renter) Enclosure 2_Renter Protocol_revised.docx	Form and Instruction
3 Flash Cards Enclosure 4_Flash Cards.docx	Form and Instruction
OMB Memo_NYCHVS 2021 Redesign 190604.docx OMB Memo	IC Document
Enclosure 3_Screener.docx Recruitment Screener	IC Document
Enclosure 5_Consent Form.docx Consent Form	IC Document
Enclosure 6_Payment Voucher.doc Voucher Form	IC Document

IC Title:

NYCHVS 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	Protocol V1 (Owner)	Enclosure 1_Owner Protocol_revised.docx	No	Fillable Fileable
Form and Instruction	2	Protocol V2 (Renter)	Enclosure 2_Renter Protocol_revised.docx	No	Fillable Fileable
Form and Instruction	3	Flash Cards	Enclosure 4_Flash Cards.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: 72

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	72	72
Annual IC Time Burden (Hours)	108	108
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
OMB Memo	OMB Memo_NYCHVS 2021 Redesign 190604.docx	06/05/2019
Recruitment Screener	Enclosure 3_Screener.docx	06/05/2019
Consent Form	Enclosure 5_Consent Form.docx	06/05/2019
Voucher Form	Enclosure 6_Payment Voucher.doc	06/05/2019

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