Information Collection

Cognitive Test for NHIS Questions and Opiods

IC 236133 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⚠️ Notice: This information collection may be referencing outdated material.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
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

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:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.