OMB Form 83-I

PAPERWORK REDUCTION ACT SUBMISSION
Please read the instructions before completing this form. For additional forms or assistance in completing this form, contact your
agency's Paperwork Clearance Officer. Send two copies of this form, the collection instrument to be reviewed, the Supporting
Statement, and any additional documentation to: Office of Information and Regulatory Affairs, Office of Management and Budget,
Docket Library, Room 10102, 725 17th Street NW, Washington, DC 20503.
2. OMB CONTROL NUMBER

1. AGENCY/SUBAGENCY ORIGINATING REQUEST

Department of Commerce/U.S. Census Bureau

a.

0990

X

b. NONE

4. TYPE OF REVIEW REQUESTED (X one)

3. TYPE OF INFORMATION COLLECTION (X one)

X
a. NEW COLLECTION

X

0607

a. REGULAR SUBMISSION
b. EMERGENCY - APPROVAL REQUESTED BY:

b. REVISION OF A CURRENTLY APPROVED COLLECTION

c. DELEGATED

c. EXTENSION OF A CURRENTLY APPROVED COLLECTION
d. REINSTATEMENT, WITHOUT CHANGE, OF A PREVIOUSLY
APPROVED COLLECTION FOR WHICH APPROVAL HAS EXPIRED

5. SMALL ENTITIES
Will this information collection have a significant economic
impact on a substantial number of small entities?

e. REINSTATEMENT, WITH CHANGE, OF A PREVIOUSLY
APPROVED COLLECTION FOR WHICH APPROVAL HAS EXPIRED

YES
X NO
6. REQUESTED EXPIRATION DATE

X

f. EXISTING COLLECTION IN USE WITHOUT AN OMB CONTROL
NUMBER

a. THREE YEARS FROM APPROVAL DATE
b. OTHER:

7. TITLE

National Survey of Children's Health
8. AGENCY FORM NUMBER(S) (if applicable)
N/A
9. KEYWORDS
N/A

10. ABSTRACT
This submission requests approval for a large-scale (N = 184,000 addresses) national Web and Paper-and-Pencil Interview (PAPI) survey. Incentives ($2 or $5) will
be included in the initial invite letter for 90% of the sample, while the other 10% of the sample will not receive an incentive as a way to monitor incentive
effectiveness. Initial paper topical mailings will also include a $5 incentive for 90% of the sample. The survey will consist of two experiments to evaluate
opportunities to incorporate efficiencies in the data collection process including the use of a redesigned envelope that is eye catching and increases the likelihood of
the package being opened and a screener card test to evaluate a streamlined process for households without children. The design & content of the 2019 NSCH survey
is based on preliminary 2018 NSCH results.
12. OBLIGATION TO RESPOND (Mark primary with "P" and all
11. AFFECTED PUBLIC (Mark primary with "P" and all others that apply with "X")
P

a. INDIVIDUALS OR HOUSEHOLDS

d. FARMS

P

e. FEDERAL GOVERNMENT

c. NOT-FOR-PROFIT INSTITUTIONS

f. STATE, LOCAL OR TRIBAL GOVERNMENT

a. NUMBER OF RESPONDENTS
b. TOTAL ANNUAL RESPONSES
(1) Percentage of these responses collected electronically
c. TOTAL ANNUAL HOURS REQUESTED
d. CURRENT OMB INVENTORY
e. DIFFERENCE (+, -)
f.

EXPLANATION OF
DIFFERENCE:

(1) Program change (+, -)

96,549
96,549
65
20,371
16,573
3,798
3,798

a. TOTAL CAPITAL/STARTUP COSTS
b. TOTAL ANNUAL COSTS (O&M)
c. TOTAL ANNUALIZED COST REQUESTED
e. DIFFERENCE (+, -)
f.

P

c. GENERAL PURPOSE STATISTICS

17. STATISTICAL METHODS
Does this information collection employ
statistical methods?
YES

OMB FORM 83-I, 10/95

NO

X

75

16. FREQUENCY OF RECORDKEEPING OR REPORTING (X all that apply)
a. RECORDKEEPING

d. AUDIT

X

EXPLANATION OF DIFFERENCE:
(1) Program change (+, -)

"P" and all others that apply with "X")

X

560
485
75

d. CURRENT OMB INVENTORY

(2) Adustment (+, -)

15. PURPOSE OF INFORMATION COLLECTION (Mark primary with

b. PROGRAM EVALUATION

c. MANDATORY

14. ANNUALIZED COST TO RESPONDENTS (In thousands of dollars)

(2) Adustment (+, -)

a. APPLICATION FOR BENEFITS

others that apply with "X")

b. REQUIRED TO OBTAIN OR RETAIN BENEFITS

b. BUSINESS OR OTHER FOR-PROFIT

13. ANNUAL REPORTING AND RECORDKEEPING HOUR BURDEN

a. VOLUNTARY

e. PROGRAM PLANNING
OR MANAGEMENT

X

f. RESEARCH
g. REGULATORY OR
COMPLIANCE

b. THIRD PARTY DISCLOSURE

c. REPORTING:
(1) On Occasion

(2) Weekly

(4) Quarterly

(5) Semi-Annually

(7) Biennially

(8) Other (Describe)

(3) Monthly

X

(6) Annually

18. AGENCY CONTACT (Person who can best answer questions regarding the content of this
submission)
a. NAME

Carolyn M. Pickering

b. TELEPHONE NUMBER (Include area code)

301-763-3873

OMB CONTROL NUMBER

0607

0990

TITLE

National Survey of Children's Health

19. CERTIFICATION FOR PAPERWORK REDUCTION ACT SUBMISSIONS
a. PROGRAM OFFICIAL CERTIFICATION (Internal DOC Use Only)
Type name Ron Jarmin, Deputy Director, U.S. Census Bureau

RON JARMIN

Digitally signed by RON JARMIN
Date: 2019.03.04 08:19:16 -05'00'

Date

03/04/2019

On behalf of this Federal agency, I certify that the collection of information encompassed by this request
complies with 5 CFR 1320.9.
NOTE: The text of 5 CFR 1320.9, and the related provisions of 5 CFR 1320.8(b)(3), appear at the end of the
instructions. The certification is to be made with reference to those regulatory provisions as set forth in the
instructions.
The following is a summary of the topics, regarding the proposed collection of information, that the
certification covers:
(a) It is necessary for the proper performance of agency functions;
(b) It avoids unnecessary duplication;
(c) It reduces burden on small entities;
(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;
(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;
(f) It indicates the retention periods for recordkeeping requirements;
(g) It informs respondents of the information called for under 5 CFR 1320.8(b)(3) about:
(i)

Why the information is being collected;

(ii) Use of information;
(iii) Burden estimate;
(iv) Nature of response (voluntary, required for a benefit, or mandatory);
(v) Nature and extent of confidentiality; and
(vi) Need to display currently valid OMB control number;
(h) It was developed by an office that has planned and allocated resources for the efficient and effective
management and use of the information to be collected (see note in Item 19 of the instructions);
(i) If applicable, it uses effective and efficient statistical survey methodology; and
(j) It makes appropriate use of information technology.
If you are unable to certify compliance with any of these provisions, identify the item below and explain the
reason in Item 18 of the Supporting Statement.

b. SENIOR OFFICIAL OR DESIGNEE CERTIFICATION
Type name

OMB FORM 83-I (BACK), 10/95

Date