National Health Interview Survey

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Reinterview Survey	Form and Instruction	Modified	Repair queued
New Supplements and Core Changes	Form and Instruction	Modified	Repair queued
Sample Child Core Questionnaire	Form and Instruction	Modified	Repair queued
Sample Adult Core Questionnaire	Form and Instruction	Modified	Available
Family Core Questionnaire	Form and Instruction	Modified	Repair queued
Att 6 rev - Detailed Methodological Projects Description.pdf	Supplementary Document	Uploaded 2016-12-28	Available
Att 10 - Adaptive Design Experiment.pdf	Supplementary Document	Uploaded 2016-11-30	Available
Att 9 rev - ERB Approval.pdf	Supplementary Document	Uploaded 2016-11-30	Available
Att 8f - University Thank You Letter.pdf	Supplementary Document	Uploaded 2016-11-30	Available
Att 8e - University Advance Letter.pdf	Supplementary Document	Uploaded 2016-11-30	Available
Att 8d - Supplementary Mailings.pdf	Supplementary Document	Uploaded 2016-11-30	Available
Att 8c rev - Thank you letter.pdf	Supplementary Document	Uploaded 2016-11-30	Available
Att 8b - NHIS Brochure.pdf	Supplementary Document	Uploaded 2016-11-30	Available
Att 8a rev2 - Advance Letter.pdf	Supplementary Document	Uploaded 2016-11-30	Available
Att 7b rev - Public Comments.pdf	Supplementary Document	Uploaded 2016-11-30	Available
Att 7a - 60 Day FRN.pdf	Supplementary Document	Uploaded 2016-11-30	Available
Att 4 - Flashcards.pdf	Supplementary Document	Uploaded 2016-11-30	Available
Att 3c - Core and Supplement Changes Summary Table.pdf	Supplementary Document	Uploaded 2016-11-30	Available
Att 3b rev - Description of Supplements.pdf	Supplementary Document	Uploaded 2016-11-30	Available
Att 2f - Additions to Core NHIS.pdf	Supplementary Document	Uploaded 2016-11-30	Available
Att 2e rev - OMB Statement and HH Comp.pdf	Supplementary Document	Uploaded 2016-11-30	Available
Att 2d - Need for Core Modules.pdf	Supplementary Document	Uploaded 2016-11-30	Available
Att 1 - Legislative Mandates.pdf	Supplementary Document	Uploaded 2016-11-30	Available
2017 NHIS SSB 111416.doc	Supporting Statement B	Uploaded 2016-11-30	Available
2017 NHIS SSA 111416.docx	Supporting Statement A	Uploaded 2016-11-30	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
214142	Methodological Projects - Adult Family Member	Other-Overview Description of Methodological and Testing Activit	Modified
214116	Reinterview Survey	Form and Instruction	Modified
214115	New Supplements and Core Changes	Form and Instruction	Modified
214114	Sample Child Core Questionnaire	Form and Instruction	Modified
214113	Sample Adult Core Questionnaire	Form and Instruction	Modified
214112	Family Core Questionnaire	Form and Instruction	Modified

ICR Details

OMB Control No: 0920-0214	ICR Reference No: 201611-0920-011
Status: Historical Active	Previous ICR Reference No: 201606-0920-006
Agency/Subagency: HHS/CDC	Agency Tracking No: 16AQB
Title: National Health Interview Survey
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 12/29/2016
	Date Received in OIRA: 12/01/2016
Terms of Clearance: CDC/NCHS may use the non-substantive change mechanism to modify existing questions, including those designed to add depth/additional detail and cycle in and out methodological modules that have been used in the past years (with modest updates). If new supplemental modules, new questionnaire instruments, or modifications to the sample are anticipated, a full revision of the ICR package must be submitted to OMB.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2019	36 Months From Approved	01/31/2019
Responses	160,000	0	160,000
Time Burden (Hours)	49,000	0	49,000
Cost Burden (Dollars)	0	0	0

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Abstract: This revision request is to conduct the National Health Interview Survey for 2017-2019; to modify selected sections of the 2017-2019 surveys; and to conduct special projects to inform the 2018 questionnaire redesign.

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Authorizing Statute(s): US Code: 42 USC 242 Name of Law: Public Health Service Act
   PL: Pub.L. 107 - 347 511 Name of Law: Confidential Information Protection and Statistical Efficiency Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 48802	07/26/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 85963	11/29/2016
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 6

table that charts list of burden

IC Title	Form No.	Form Name
Sample Adult Core Questionnaire	N/A	2017 Sample Adult Questionnaire
Methodological Projects - Adult Family Member
Family Core Questionnaire	N/A	2017 Family Questionnaire with LOI
Sample Child Core Questionnaire	N/A	2017 Sample Child Questionnaire
New Supplements and Core Changes	N/A	2017 New Supplement Questions
Reinterview Survey	N/A	2017 Reinterview Questionnaire

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ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	160,000	160,000	0	0	0	0
Annual Time Burden (Hours)	49,000	49,000	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $42,000,000

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Yes

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 12/01/2016

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