Information Collection

Cognitive Test for ACS Disability Questions and NHIS Child Behavior Questions

IC 236115 under ICR 201807-0920-004 · OMB 0920-0222.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0222 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Cognitive Test for ACS Disability Questions and NHIS Child Behavior Questions	Form and Instruction
Telephone Screener 0920-0222 Attach 3ab Telephone Screeners ACS & NHIS.doc	Form and Instruction
ACS Booklet and Selected NHIS Questions Discussed During 0920-0222 Attach 1 ACS Disability & NHIS Child Behavavior.pdf	Form and Instruction
Respondent Data Collection Sheet (Demographics) 0920-0222 Attach 5 Resp Data ACS & NHIS.doc	Form and Instruction
0920-0222 Justification Cognitive Testing ACS and NHIS Questions.doc Project Description and Justification	IC Document
0920-0222 Attach 2ab Adsflyers ACS & NHIS.doc Recruitment Materials	IC Document
0920-0222 Attach 4 Informed Consent ACS & NHIS Questions.doc Informed Consent	IC Document
0920-0222 Attach 6 Thank You Letter ACS & NHIS.doc Thank-you Letter	IC Document

IC Title:

Cognitive Test for ACS Disability Questions and NHIS Child Behavior Questions

Agency IC Tracking Number:

0920-19AYX

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	n/a	Telephone Screener	0920-0222 Attach 3ab Telephone Screeners ACS & NHIS.doc	No	Paper Only
Form and Instruction	n/a	ACS Booklet and Selected NHIS Questions Discussed During the Cognitive Interview	0920-0222 Attach 1 ACS Disability & NHIS Child Behavavior.pdf	No	Paper Only
Form and Instruction	n/a	Respondent Data Collection Sheet (Demographics)	0920-0222 Attach 5 Resp Data ACS & NHIS.doc	No	Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: Health and Demographic Surveys Conducted in Probability Samples of the U. S. Population, SORN 09-20-0164

FR Citation: 49 FR 37693

Number of Respondents: 80

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	80	80
Annual IC Time Burden (Hours)	47	47
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Project Description and Justification	0920-0222 Justification Cognitive Testing ACS and NHIS Questions.doc	05/16/2019
Recruitment Materials	0920-0222 Attach 2ab Adsflyers ACS & NHIS.doc	05/16/2019
Informed Consent	0920-0222 Attach 4 Informed Consent ACS & NHIS Questions.doc	05/16/2019
Thank-you Letter	0920-0222 Attach 6 Thank You Letter ACS & NHIS.doc	05/16/2019

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