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⚠️ Notice: This information collection may be referencing outdated material.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

Document Name Document Type
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

Information Collection (IC) Details

View Information Collection (IC)

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:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	none	Paper screener using Roster Method	AttE.4a_Paper Screener Using Roster Method.docx		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 %

	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

Title	Document	Date Uploaded
Description of Program Changes/Adjustments	Att A. Description of Program Changes and Adjustments OMB_CDC revision_CLEAN 6.10.19.docx	06/14/2019
Cognitive Testing Plan	Att F. Cognitive Testing Plan.docx	06/14/2019
Cognitive Testing Recruitment Ad	Att G. Cog Testing Recruitment Ad.docx	06/14/2019
Web-based Recruitment Screener	Att H. Recruiting Screener.docx	06/14/2019
Cognitive Testing Informed Consent	Att I. Cog Testing Informed Consent.docx	06/14/2019
CATI Instrument Cognitive Testing Protocol	Att J. CATI Instrument Cog Testing Protocol.docx	06/14/2019
PAPER Instrument Cognitive Testing Protocol	Att K. Paper Instrument Cog Testing Protocol.docx	06/14/2019
WEB-BASED Instrument Cognitive Testing Protocol	Att L. Web-based Instrument Cog Testing Protocol.docx	06/14/2019
Crosswalk of NISVS Instrument Revisions	Att. B Crosswalk of NISVS Instrument Revisions for OMB_CDC revision_CLEAN_6.6.19.docx	06/14/2019

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