Gender X Marker

Collaborating Center for Questionnaire Design and Evaluation Research

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0222 can be found here:

Documents and Forms

Document Name Document Type
Attachment 1 - Passport Application Form.docx Other-Draft Modified Form with Quest
Screening Questions for Potential Respondents Attachment 3 - Screener.docx Form and Instruction
Informed Consent Attachment 4v2 - Informed Consent.docx Form and Instruction
Respondent Data Collection Sheet Attachment 5- Respondent Data Collection Sheet.docx Form and Instruction
Gender X 10-day-letter-111821 Clean SK.docx Project Description and Justification (10-day letter) IC Document
Attachment 2- Non-Specific Advertisement.docx Recruitment Advertisement IC Document
Attachment 6-Data Retention Policy_ 102121.docx Data Retention Policy IC Document

Information Collection (IC) Details

IC Title:	Gender X Marker	Agency IC Tracking Number:	0920-22AY

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Draft Modified Form with Questions to be Tested			Attachment 1 - Passport Application Form.docx	Yes	Yes	Fillable Printable
Form and Instruction	n/a	Screening Questions for Potential Respondents	Attachment 3 - Screener.docx	Yes	Yes	Fillable Fileable
Form and Instruction	n/a	Informed Consent	Attachment 4v2 - Informed Consent.docx	Yes	Yes	Fillable Fileable
Form and Instruction	n/a	Respondent Data Collection Sheet	Attachment 5- Respondent Data Collection Sheet.docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title: 09-20-0164 Health and Demographic Surveys Conducted in Probability Samples of the U.S. Population	FR Citation: 49 FR 37693

Number of Respondents: 150	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	150	150
Annual IC Time Burden (Hours)	129	129
Annual IC Cost Burden (Dollars)	1,074	1,074

Documents for IC

Title	Document	Date Uploaded
Project Description and Justification (10-day letter)	Gender X 10-day-letter-111821 Clean SK.docx	11/18/2021
Recruitment Advertisement	Attachment 2- Non-Specific Advertisement.docx	11/18/2021
Data Retention Policy	Attachment 6-Data Retention Policy_ 102121.docx	11/18/2021

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