Cognitive Test for ACS Disability Questions and NHIS Child Behavior Questions

Collaborating Center for Questionnaire Design and Evaluation Research

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

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

Information Collection (IC) Details

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:

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 %

	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

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.