Information Collection

NIOSH Virtual Cognitive Interview Study

IC 243825 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⚠️ Notice: This information collection may be referencing outdated material.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
NIOSH Virtual Cognitive Interview Study	Form and Instruction
Telephone screener Att 4ab - NIOSH Virtual Telephone Screener.docx	Form and Instruction
NIOSH questionnaire Att 2 NIOSH Virtual Questionnaire 2-24-2020.docx	Form and Instruction
Respondent data sheet Att 6ab - NIOSH Virtual Respondent Data Sheet.docx	Form and Instruction
Att 1 - NIOSH Response to Qs- 2-24-2020.docx NIOSH response to OMB questions	IC Document
Att 3ab - NIOSH Virtual AdFlyer.docx Advertisement flyer	IC Document
Att 5ab - NIOSH Virtual Informed Consent.docx Consent	IC Document
Att 7 NIOSH Virtual Thank You Letter.docx Thank you letter	IC Document
10-day letter_NIOSH Virtual_Sept 30 2020-CLEAN.docx Letter of request	IC Document

IC Title:

NIOSH Virtual Cognitive Interview Study

Agency IC Tracking Number:

0920-0222-20SJ

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 screener	Att 4ab - NIOSH Virtual Telephone Screener.docx	Yes	Yes	Fillable Fileable
Form and Instruction	none	NIOSH questionnaire	Att 2 NIOSH Virtual Questionnaire 2-24-2020.docx	Yes	Yes	Fillable Fileable
Form and Instruction	none	Respondent data sheet	Att 6ab - NIOSH Virtual Respondent Data Sheet.docx	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: 90

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	90	90
Annual IC Time Burden (Hours)	31	31
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
NIOSH response to OMB questions	Att 1 - NIOSH Response to Qs- 2-24-2020.docx	09/30/2020
Advertisement flyer	Att 3ab - NIOSH Virtual AdFlyer.docx	09/30/2020
Consent	Att 5ab - NIOSH Virtual Informed Consent.docx	09/30/2020
Thank you letter	Att 7 NIOSH Virtual Thank You Letter.docx	09/30/2020
Letter of request	10-day letter_NIOSH Virtual_Sept 30 2020-CLEAN.docx	10/01/2020

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