Information Collection

2021 AHS Cognitive Testing

IC 242289 under ICR 201909-0607-002 · OMB 0607-0725.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0607-0725 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 2021 AHS Cognitive Testing	Form and Instruction
1 Protocol and Questionnaire for Cognitive Interviews Enclosure 1 - AHS 2021 Protocol_In Person & Remote Interviews.docx	Form and Instruction
2 Qualtrics Survey Questionnaire Enclosure 5-Qualtrics Survey Questionnaire_FINAL_07292020.docx	Form and Instruction
OMB Memo_AHS 2021 Cognitive Testing_FINAL_07292020.docx OMB Memo	IC Document
Enclosure 2 - Recruitment Screener w PA Language_clean.docx Screener	IC Document
Enclosure 3a - AHS Combo Ad_BOC Email and Craigslist.docx BOC and Craigslist Ads	IC Document
Enclosure 3b - AHS 2021 recruiting flyer.pub Ad Flyer	IC Document
Enclosure 4-Consent Form w PA Language_clean.docx Consent Form	IC Document
Screener Part A-clean.docx Previously Approved Universal Screener w/ privacy language	IC Document

IC Title:

2021 AHS Cognitive Testing

Agency IC Tracking Number:

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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	1	Protocol and Questionnaire for Cognitive Interviews	Enclosure 1 - AHS 2021 Protocol_In Person & Remote Interviews.docx		No		Fillable Fileable
Form and Instruction	2	Qualtrics Survey Questionnaire	Enclosure 5-Qualtrics Survey Questionnaire_FINAL_07292020.docx		No		Fillable Fileable

Line of Business: General Government

Subfunction: Central Records & Statistical Mgt

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 165

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 91 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	165	165
Annual IC Time Burden (Hours)	56	56
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
OMB Memo	OMB Memo_AHS 2021 Cognitive Testing_FINAL_07292020.docx	07/30/2020
Screener	Enclosure 2 - Recruitment Screener w PA Language_clean.docx	07/06/2020
BOC and Craigslist Ads	Enclosure 3a - AHS Combo Ad_BOC Email and Craigslist.docx	06/17/2020
Ad Flyer	Enclosure 3b - AHS 2021 recruiting flyer.pub	06/17/2020
Consent Form	Enclosure 4-Consent Form w PA Language_clean.docx	07/06/2020
Previously Approved Universal Screener w/ privacy language	Screener Part A-clean.docx	07/06/2020

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