Information Collection

Phase 2 - ABS, paper screener, Roster method

IC 230016 under ICR 202105-0920-008 · OMB 0920-0822.

⚠️ Notice: This information collection may be referencing outdated material.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

2025-03-28 - No material or nonsubstantive change to a currently approved collection
2023-11-09 - No material or nonsubstantive change to a currently approved collection

Documents and Forms

Documents and forms in this information collection
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
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 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 F. Cognitive Testing Plan.docx Cognitive Testing Plan	IC Document
Att G. Cog Testing Recruitment Ad.docx Cognitive Testing Recruitment Ad	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 H. Recruiting Screener.docx Web-based Recruitment Screener	IC Document
Att I. Cog Testing Informed Consent.docx Cognitive Testing Informed Consent	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 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 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 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
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: Removed

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	Paper screener using Roster Method	AttE.4a_Paper Screener Using Roster Method.docx		No		Paper Only

Federal Enterprise Architecture Business Reference Module

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
	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	-389	389
Annual IC Time Burden (Hours)	-19	19
Annual IC Cost Burden (Dollars)	-514	514

Documents for IC

table that charts IC Documents
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.