Information Collection

NSFG Life History Calendar Evaluation

IC 238942 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⚠️ Notice: This information collection may be referencing outdated material.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 NSFG Life History Calendar Evaluation	Form and Instruction
0920-0222 Attachment 1a: Questions to be cognitively tested Att 1a-NSFG LHC Questions.doc	Form and Instruction
0920-0222 Attachment 1b - Life History Calendar Worksheet (Recall Att 1b-NSFG LHC-Recall Aide.pdf	Form and Instruction
0920-0222 Attachment 3a – Telephone Screening Script – Respondent Att 3a-NSFG LHC-Screener adv&flyer.doc	Form and Instruction
0920-0222 Attachment 3b – Telephone Screening Script – Respondent Att 3b-NSFG LHC-Screener adv&flyer.doc	Form and Instruction
0920-0222 Attachment 5: Respondent Data Collection Sheet Att 5-NSFG LHC Resp Data Collect.doc	Form and Instruction
NSFG LHC 10-Day Letter 121219.docx 10 Day Letter	IC Document
Att 2-NSFG LHC Ad&Flyer.doc Attachment 2: Advertisement/flyer.	IC Document
Att 4-NSFG LHC Consent.doc Attachment 4 – Adult Informed Consent	IC Document
Att 6-NSFG LHC ThankYou ltr.doc Attachment 6 – Thank you letter	IC Document

IC Title:

NSFG Life History Calendar Evaluation

Agency IC Tracking Number:

0920-20EH

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	0920-0222	Attachment 1a: Questions to be cognitively tested	Att 1a-NSFG LHC Questions.doc	Yes	Yes	Fillable Printable
Form and Instruction	0920-0222	Attachment 1b - Life History Calendar Worksheet (Recall Aide)	Att 1b-NSFG LHC-Recall Aide.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	0920-0222	Attachment 3a â Telephone Screening Script â Respondent recruited from newspaper advertisement/flyer	Att 3a-NSFG LHC-Screener adv&flyer.doc	Yes	Yes	Fillable Fileable
Form and Instruction	0920-0222	Attachment 3b â Telephone Screening Script â Respondent recruited from CCQDER Respondent Database	Att 3b-NSFG LHC-Screener adv&flyer.doc	Yes	Yes	Fillable Fileable
Form and Instruction	0920-0222	Attachment 5: Respondent Data Collection Sheet	Att 5-NSFG LHC Resp Data Collect.doc	Yes	Yes	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: 120

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	120	120
Annual IC Time Burden (Hours)	36	36
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
10 Day Letter	NSFG LHC 10-Day Letter 121219.docx	12/16/2019
Attachment 2: Advertisement/flyer.	Att 2-NSFG LHC Ad&Flyer.doc	12/16/2019
Attachment 4 â Adult Informed Consent	Att 4-NSFG LHC Consent.doc	12/16/2019
Attachment 6 â Thank you letter	Att 6-NSFG LHC ThankYou ltr.doc	12/16/2019

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