Information Collection

Cognitive Testing of 2021 Occupational Health Supplement Questions

IC 240112 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⚠️ Notice: This information collection may be referencing outdated material.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

Document Name Document Type
Form 0920-0222 Cognitive Testing of 2021 Occupational Health Supplement Questions Form
Att 4ab - NIOSH telephone screener 020420-lc.docx Instruction
0920-0222 Questions for Consideration NHIS-OHS 2021 Supplement Att 2 - Questionnaire-2-24-2020.docx Form
0920-0222 Respondent Data Collection Sheet Att 6 - NIOSH Resp Data Collect Sheet.docx Form
10-day letter_NIOSH_12-11-2020_REVISED-2-24-2020-CLEAN.docx 10-day Letter IC Document
Att 1 - NIOSH Response to Qs 11-12-2019-REVISED-2-24-2020- CLEAN.docx NIOSH Res[ponse to Questions Raised by OMB IC Document
Att 3ab - NIOSH Ad&Flyer.docx Att 3a Semi-targeted Advertisement IC Document
Att 5 - NIOSH informed consent 1121 2019-kw--1-9-2020-CLEAN.docx Att 5_Adult Informed Consernt Form for One-on-One Interviews IC Document
Att 7 - NIOSH Thank You Letter-1121 2019.docx Att 7_Thank you letter IC Document
Att 8 - NIOSH Special Consent.docx Att 8_Special Consent for Expanded Use of Video and Audio Recordings IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Cognitive Testing of 2021 Occupational Health Supplement Questions	Agency IC Tracking Number:	0920-0222-20KP

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Electronic Capability
Form	0920-0222	Questions for Consideration NHIS-OHS 2021 Supplement	Att 2 - Questionnaire-2-24-2020.docx	No	Fillable Fileable
Instruction			Att 4ab - NIOSH telephone screener 020420-lc.docx	No	Printable Only
Form	0920-0222	Respondent Data Collection Sheet	Att 6 - NIOSH Resp Data Collect Sheet.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: 75	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	75	75
Annual IC Time Burden (Hours)	23	23
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
10-day Letter	10-day letter_NIOSH_12-11-2020_REVISED-2-24-2020-CLEAN.docx	02/26/2020
NIOSH Res[ponse to Questions Raised by OMB	Att 1 - NIOSH Response to Qs 11-12-2019-REVISED-2-24-2020- CLEAN.docx	02/26/2020
Att 3a Semi-targeted Advertisement	Att 3ab - NIOSH Ad&Flyer.docx	02/26/2020
Att 5_Adult Informed Consernt Form for One-on-One Interviews	Att 5 - NIOSH informed consent 1121 2019-kw--1-9-2020-CLEAN.docx	02/26/2020
Att 7_Thank you letter	Att 7 - NIOSH Thank You Letter-1121 2019.docx	02/26/2020
Att 8_Special Consent for Expanded Use of Video and Audio Recordings	Att 8 - NIOSH Special Consent.docx	02/26/2020

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