OMB
.report
Search
NIOSH Virtual Cognitive Interview Study
Collaborating Center for Questionnaire Design and Evaluation Research
OMB: 0920-0222
IC ID: 243825
OMB.report
HHS/CDC
OMB 0920-0222
ICR 201807-0920-004
IC 243825
( )
⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0222 can be found here:
2022-12-21 - Revision of a currently approved collection
2021-08-16 - Revision of a currently approved collection
Documents and Forms
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
Information Collection (IC) Details
View Information Collection (IC)
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:
Document Type
Form No.
Form Name
Instrument File
URL
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
Federal Enterprise Architecture Business Reference Module
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 %
Approved
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
90
0
90
0
0
0
Annual IC Time Burden (Hours)
31
0
31
0
0
0
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
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.