Cognitive Testing of Physician Opioid 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⚠️ Notice: This information collection may be referencing outdated material.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 Testing of Physician Opioid Questions Form
0920-0222 Attach 4 Telephone Screener Physician Opioid.docx Other-Telephone script
National Survey on Best Practices for Patient Pain Manag 0920-0222 Attach 1 Qnne Physician Opioid.docx Form
Respondent data collection sheet 0920-0222 Attach 6 Resp Data Physician Opioid.docx Form
0920-0222 Physician Opioid 10day sk-6.6.19.docx Letter to Dr. Schwab IC Document
0920-0222 Attach 3 Advance Letter Physician Opioid.docx Advance letter IC Document
0920-0222 Attach 5 Informed Consent Physician Opioid.docx Consent IC Document
0920-0222 Attach 7 Thank You letter Physician Opioid.docx Thank you letter IC Document
0920-0222 Attach 2 Card Sort Physician Opioid-revised.docx Card sort IC Document

Information Collection (IC) Details

IC Title:	Cognitive Testing of Physician Opioid Questions	Agency IC Tracking Number:	0920-0222-19BGE

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	none	National Survey on Best Practices for Patient Pain Management and Opioid Use	0920-0222 Attach 1 Qnne Physician Opioid.docx	Yes	Yes	Fillable Fileable
Other-Telephone script			0920-0222 Attach 4 Telephone Screener Physician Opioid.docx	Yes	Yes	Fillable Fileable
Form	none	Respondent data collection sheet	0920-0222 Attach 6 Resp Data Physician Opioid.docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 90	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	90	90
Annual IC Time Burden (Hours)	26	26
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Letter to Dr. Schwab	0920-0222 Physician Opioid 10day sk-6.6.19.docx	06/06/2019
Advance letter	0920-0222 Attach 3 Advance Letter Physician Opioid.docx	06/06/2019
Consent	0920-0222 Attach 5 Informed Consent Physician Opioid.docx	06/06/2019
Thank you letter	0920-0222 Attach 7 Thank You letter Physician Opioid.docx	06/06/2019
Card sort	0920-0222 Attach 2 Card Sort Physician Opioid-revised.docx	06/06/2019

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