Cognitive Testing for American Community Survey

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⚠️ Notice: This information collection may be referencing outdated material.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 for American Community Survey Form and Instruction
Telephone screeners 0920-0222 Attach 3ab Telephone screeners.docx Form and Instruction
Interview instrument 0920-0222 Attach 1 Instrument.docx Form
Respondent data collection sheets 0920-0222 Attach 5 Resp Data.doc Form
0920-0222 Attach 2abc ads&flyers.docx Advertisements and flyers IC Document
0920-0222 Attach 4 Informed Consent.docx Consent IC Document
0920-0222 Attach 6 Thank You Letter ACS & NHIS.doc Thank you letter IC Document
0920-0222 Justification ACS and NHIS Questions 081919.doc Letter to Dr. Schwab IC Document

Information Collection (IC) Details

IC Title:	Cognitive Testing for American Community Survey	Agency IC Tracking Number:	0920-0222-19BOG

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 and Instruction	none	Telephone screeners	0920-0222 Attach 3ab Telephone screeners.docx	Yes	No	Paper Only
Form	none	Interview instrument	0920-0222 Attach 1 Instrument.docx	Yes	No	Paper Only
Form	none	Respondent data collection sheets	0920-0222 Attach 5 Resp Data.doc	Yes	No	Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 400	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	400	400
Annual IC Time Burden (Hours)	119	119
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Advertisements and flyers	0920-0222 Attach 2abc ads&flyers.docx	08/19/2019
Consent	0920-0222 Attach 4 Informed Consent.docx	08/19/2019
Thank you letter	0920-0222 Attach 6 Thank You Letter ACS & NHIS.doc	08/19/2019
Letter to Dr. Schwab	0920-0222 Justification ACS and NHIS Questions 081919.doc	08/19/2019

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