Information Collection

Cognitive Testing for American Community Survey

IC 237460 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⚠️ Notice: This information collection may be referencing outdated material.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
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

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:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.