Information Collection

Phase 2 - ABS, paper screener, Roster method

IC 230016 under ICR 202001-0920-001 · OMB 0920-0822.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0822 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Paper screener using Roster Method Phase 2 - ABS, paper screener, Roster method	Form and Instruction
Paper screener using Roster Method AttE.4a_Paper Screener Using Roster Method.docx	Form and Instruction
Att A. Description of Program Changes and Adjustments OMB_CDC revision_CLEAN 6.10.19.docx Description of Program Changes/Adjustments	IC Document
Att F. Cognitive Testing Plan.docx Cognitive Testing Plan	IC Document
Att G. Cog Testing Recruitment Ad.docx Cognitive Testing Recruitment Ad	IC Document
Att H. Recruiting Screener.docx Web-based Recruitment Screener	IC Document
Att I. Cog Testing Informed Consent.docx Cognitive Testing Informed Consent	IC Document
Att J. CATI Instrument Cog Testing Protocol.docx CATI Instrument Cognitive Testing Protocol	IC Document
Att K. Paper Instrument Cog Testing Protocol.docx PAPER Instrument Cognitive Testing Protocol	IC Document
Att L. Web-based Instrument Cog Testing Protocol.docx WEB-BASED Instrument Cognitive Testing Protocol	IC Document
Att. B Crosswalk of NISVS Instrument Revisions for OMB_CDC revision_CLEAN_6.6.19.docx Crosswalk of NISVS Instrument Revisions	IC Document

IC Title:

Phase 2 - ABS, paper screener, Roster method

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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	none				No		Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: Epidemiologic Studies and Surveillance of Disease Problems

FR Citation: 57 FR 62812

Number of Respondents: 389

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	389	-5,311	5,700
Annual IC Time Burden (Hours)	19	-2,617	2,636
Annual IC Cost Burden (Dollars)	514	514	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Description of Program Changes/Adjustments		06/14/2019
Cognitive Testing Plan		06/14/2019
Cognitive Testing Recruitment Ad		06/14/2019
Web-based Recruitment Screener		06/14/2019
Cognitive Testing Informed Consent		06/14/2019
CATI Instrument Cognitive Testing Protocol		06/14/2019
PAPER Instrument Cognitive Testing Protocol		06/14/2019
WEB-BASED Instrument Cognitive Testing Protocol		06/14/2019
Crosswalk of NISVS Instrument Revisions		06/14/2019

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

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