NHANES Questionnaire

National Health and Nutrition Examination Survey

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0950 can be found here:

Documents and Forms

Document Name Document Type
Form 0920-0950 NHANES Questionnaire Form
0920-0950 NHANES Questionnaire and Data Collection Forms 2017-18 Att_3b_Questionnaires 101816.docx Form
Att_3a_Question Changes100516.docx Att 3a_Summary of 2017-18 Questionnaire Changes IC Document
Att_3c _Questionnaire 15-16 101816.docx Att 3c_Questionnaire & Data Collections FOrms 2015-16 IC Document
Att_3d HH_Hand Cards 15-16.docx Att 3d_Hand Cards 2015-16 IC Document
Att_8 _Letters_scripts 17-18 100516.docx Att 8 Letters_scripts IC Document
Att_9a_Consents_17-18 100516.docx Att 9a_Consent Forms IC Document
ATT_9b_Adult Consent Brochure 100516.pdf Att 9b_Adult Consent Brochure IC Document
Att_9c_Child_Assent_17-18 062818.docx Att 9c_ Child Assent Brochure IC Document
Att_9d_Consents FAQ_17-18 101816.docx Att 9d_Consents FAQ IC Document

Information Collection (IC) Details

IC Title:	NHANES Questionnaire	Agency IC Tracking Number:	0920-0950

Is this a Common Form? No		IC Status: Unchanged

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	0920-0950	NHANES Questionnaire and Data Collection Forms 2017-18	Att_3b_Questionnaires 101816.docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title: Health and Demographic Surveys Conducted in Probability Samples of the US Population	FR Citation: 49 FR 37693

Number of Respondents: 14,410	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	14,410	14,410
Annual IC Time Burden (Hours)	36,025	36,025
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Att 3a_Summary of 2017-18 Questionnaire Changes	Att_3a_Question Changes100516.docx	11/01/2016
Att 3c_Questionnaire & Data Collections FOrms 2015-16	Att_3c _Questionnaire 15-16 101816.docx	11/01/2016
Att 3d_Hand Cards 2015-16	Att_3d HH_Hand Cards 15-16.docx	11/01/2016
Att 8 Letters_scripts	Att_8 _Letters_scripts 17-18 100516.docx	11/01/2016
Att 9a_Consent Forms	Att_9a_Consents_17-18 100516.docx	11/01/2016
Att 9b_Adult Consent Brochure	ATT_9b_Adult Consent Brochure 100516.pdf	11/01/2016
Att 9c_ Child Assent Brochure	Att_9c_Child_Assent_17-18 062818.docx	11/01/2016
Att 9d_Consents FAQ	Att_9d_Consents FAQ_17-18 101816.docx	11/01/2016

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