2021 AHS Cognitive Testing

Generic Clearance for Questionnaire Pretesting Research

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

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

Information Collection (IC) Details

IC Title:	2021 AHS Cognitive Testing	Agency IC Tracking Number:

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	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 %

	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

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.