Form 83-I

PAPERWORK REDUCTION ACT SUBMISSION
Please read the instructions before completing this form. For additional forms or assistance in completing this form, contact your
agency's Paperwork Clearance Officer. Send two copies of this form, the collection instrument to be reviewed, the Supporting
Statement, and any additional documentation to: Office of Information and Regulatory Affairs, Office of Management and Budget,
Docket Library, Room 10102, 725 17th Street NW, Washington, DC 20503.
2. OMB CONTROL NUMBER

1. AGENCY/SUBAGENCY ORIGINATING REQUEST

DOC/BOC
a.

X

b. NONE

4. TYPE OF REVIEW REQUESTED (X one)

3. TYPE OF INFORMATION COLLECTION (X one)

X

a. NEW COLLECTION

X

0990

0607

a. REGULAR SUBMISSION
b. EMERGENCY - APPROVAL REQUESTED BY:

b. REVISION OF A CURRENTLY APPROVED COLLECTION

c. DELEGATED

c. EXTENSION OF A CURRENTLY APPROVED COLLECTION
d. REINSTATEMENT, WITHOUT CHANGE, OF A PREVIOUSLY
APPROVED COLLECTION FOR WHICH APPROVAL HAS EXPIRED

5. SMALL ENTITIES
Will this information collection have a significant economic
impact on a substantial number of small entities?

e. REINSTATEMENT, WITH CHANGE, OF A PREVIOUSLY
APPROVED COLLECTION FOR WHICH APPROVAL HAS EXPIRED

6. REQUESTED EXPIRATION DATE

f. EXISTING COLLECTION IN USE WITHOUT AN OMB CONTROL
NUMBER

X

YES

X

NO

a. THREE YEARS FROM APPROVAL DATE
b. OTHER:

7. TITLE

National Survey of Children's Health
8. AGENCY FORM NUMBER(S) (if applicable)

N/A
9. KEYWORDS

N/A
10. ABSTRACT
This sumbission requests approval for a large-scale (N = 156,054 addresses) national Web and Paper-and-Pencil Interview (PAPI) survey. Incentives ($2 bill) will
be included in the initial invite letter for 90% of the sample, while the other 10% of the sample will not receive an incentive as a way to monitor incentive
effectiveness. The survey will consist of two experiments to evaluate opportunities to incorporate efficiencies in the data collection process. The first experiment
will test the efficacy of an infographic in the initial mail package and conditional upon funding, the second experiment will test the efficacy of incentives in the
topical mailings. The design and content of the NSCH 2017 survey is based on preliminary 2016 NSCH results.
12. OBLIGATION TO RESPOND (Mark primary with "P" and all
11. AFFECTED PUBLIC (Mark primary with "P" and all others that apply with "X")

P

P

a. INDIVIDUALS OR HOUSEHOLDS

d. FARMS

b. BUSINESS OR OTHER FOR-PROFIT

e. FEDERAL GOVERNMENT

c. NOT-FOR-PROFIT INSTITUTIONS

f. STATE, LOCAL OR TRIBAL GOVERNMENT

13. ANNUAL REPORTING AND RECORDKEEPING HOUR BURDEN
a. NUMBER OF RESPONDENTS
b. TOTAL ANNUAL RESPONSES
(1) Percentage of these responses collected electronically
c. TOTAL ANNUAL HOURS REQUESTED

81,805
81,805
60
16,573

b. REQUIRED TO OBTAIN OR RETAIN BENEFITS

a. TOTAL CAPITAL/STARTUP COSTS
b. TOTAL ANNUAL COSTS (O&M)
c. TOTAL ANNUALIZED COST REQUESTED

$1,372

$-941

54,117

e. DIFFERENCE (+, -)

-37,544

f.

(1) Program change (+, -)

16. FREQUENCY OF RECORDKEEPING OR REPORTING (X all that apply)

"P" and all others that apply with "X")

P

c. GENERAL PURPOSE STATISTICS

a. RECORDKEEPING

X

e. PROGRAM PLANNING
OR MANAGEMENT

X

f. RESEARCH
g. REGULATORY OR
COMPLIANCE

d. AUDIT

17. STATISTICAL METHODS
Does this information collection employ
statistical methods?

X

YES

OMB FORM 83-I, 10/95

NO

$-941

(2) Adustment (+, -)

15. PURPOSE OF INFORMATION COLLECTION (Mark primary with

b. PROGRAM EVALUATION

EXPLANATION OF DIFFERENCE:
(1) Program change (+, -)

-37,544

(2) Adustment (+, -)

a. APPLICATION FOR BENEFITS

$431

d. CURRENT OMB INVENTORY

e. DIFFERENCE (+, -)
EXPLANATION OF
DIFFERENCE:

c. MANDATORY

14. ANNUALIZED COST TO RESPONDENTS (In thousands of dollars)

d. CURRENT OMB INVENTORY
f.

others that apply with "X")

a. VOLUNTARY

X

b. THIRD PARTY DISCLOSURE

c. REPORTING:
(1) On Occasion

(2) Weekly

(4) Quarterly

(5) Semi-Annually

(7) Biennially

(8) Other (Describe)

(3) Monthly

X

(6) Annually

18. AGENCY CONTACT (Person who can best answer questions regarding the content of this
submission)
a. NAME

Jason M. Fields

b. TELEPHONE NUMBER (Include area code)

301-763-2465

OMB CONTROL NUMBER

0607

0990

TITLE

National Survey of Children's Health

19. CERTIFICATION FOR PAPERWORK REDUCTION ACT SUBMISSIONS
a. PROGRAM OFFICIAL CERTIFICATION (Internal DOC Use Only)
Type name

Date

John H. Thompson, Director, U.S. Census Bureau
On behalf of this Federal agency, I certify that the collection of information encompassed by this request
complies with 5 CFR 1320.9.
NOTE: The text of 5 CFR 1320.9, and the related provisions of 5 CFR 1320.8(b)(3), appear at the end of the
instructions. The certification is to be made with reference to those regulatory provisions as set forth in the
instructions.
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 (see note in Item 19 of the instructions);
(i) If applicable, it uses effective and efficient statistical survey methodology; and
(j) It makes appropriate use of information technology.
If you are unable to certify compliance with any of these provisions, identify the item below and explain the
reason in Item 18 of the Supporting Statement.

b. SENIOR OFFICIAL OR DESIGNEE CERTIFICATION
Type name

Jennifer Jessup, Departmental Paperwork Clearance Officer
OMB FORM 83-I (BACK), 10/95

Date