Cognitive Test for NHIS Questions and Opiods

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⚠️ Notice: This information collection may be referencing outdated material.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
Form 0920-0222 Cognitive Test for NHIS Questions and Opiods Form and Instruction
0920-0222 Questions to be Cognitively Tested GenIC 0920-0222 Cognitive Test NHIS & CCQDER Attach 1 Questions.docx Form and Instruction
0920-0222 Screeners GenIC 0920-0222 Cognitive Test NHIS & CCQDER Attach 3ab Screeners.docx Form and Instruction
0920-0222 Respondent Data Collection Sheet GenIC 0920-0222 Cognitive Test NHIS & CCQDER Attach 5 Resp Data.docx Form and Instruction
GenIC 0920-0222 NHIS and CCQDER 10-day letter 05 03 2019 ICRO.doc 10 Day Letter (GenIC info) IC Document
GenIC 0920-0222 Cognitive Test NHIS & CCQDER Attach 2ab Ads.docx Ads IC Document
GenIC 0920-0222 Cognitive Test NHIS & CCQDER Attach 4 Consent.docx Consent IC Document
GenIC 0920-0222 Cognitive Test NHIS & CCQDER Attach 6 Letter.docx Thank You Letter IC Document
GenIC 0920-0222 Cognitive Test NHSI & CCQDER Attach 7 Special Consent.docx Special Consent IC Document

Information Collection (IC) Details

IC Title:	Cognitive Test for NHIS Questions and Opiods	Agency IC Tracking Number:	0920-0222-19AUJ

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	0920-0222	Questions to be Cognitively Tested	GenIC 0920-0222 Cognitive Test NHIS & CCQDER Attach 1 Questions.docx	No	Fillable Fileable
Form and Instruction	0920-0222	Screeners	GenIC 0920-0222 Cognitive Test NHIS & CCQDER Attach 3ab Screeners.docx	No	Fillable Fileable
Form and Instruction	0920-0222	Respondent Data Collection Sheet	GenIC 0920-0222 Cognitive Test NHIS & CCQDER Attach 5 Resp Data.docx	No	Fillable Fileable

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 09-20-0164	FR Citation: 49 FR 37693

Number of Respondents: 160	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	160	160
Annual IC Time Burden (Hours)	49	49
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
10 Day Letter (GenIC info)	GenIC 0920-0222 NHIS and CCQDER 10-day letter 05 03 2019 ICRO.doc	05/20/2019
Ads	GenIC 0920-0222 Cognitive Test NHIS & CCQDER Attach 2ab Ads.docx	05/20/2019
Consent	GenIC 0920-0222 Cognitive Test NHIS & CCQDER Attach 4 Consent.docx	05/20/2019
Thank You Letter	GenIC 0920-0222 Cognitive Test NHIS & CCQDER Attach 6 Letter.docx	05/20/2019
Special Consent	GenIC 0920-0222 Cognitive Test NHSI & CCQDER Attach 7 Special Consent.docx	05/20/2019

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