Information Collection

Cognitive Testing

IC 214643 under ICR 202203-0920-009 · OMB 0920-0621.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0621 can be found here:

2024-01-19 - Revision of a currently approved collection

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Cognitive Testing for NYTS.docx	Instruction
Cognitive Testing for NYTS.docx	Instruction
0920-0621 NYTS Cognitive Testing Parent/ Guardian Screener Attachment R2_NYTS Cog Testing Parent Screener_(2022.03.29).docx	Form and Instruction
0920-0621 NYTS Cognitive Testing Parent/ Guardian Screener Attachment R2_NYTS Cog Testing Parent Screener_(2022.03.29).docx	Form and Instruction
0920-0621 NYTS Cognitive Testing Youth Screener Attachment R5_NYTS Cog Testing Youth Screener_(2022.03.29).docx	Form and Instruction
0920-0621 NYTS Cognitive Testing Youth Screener Attachment R5_NYTS Cog Testing Youth Screener_(2022.03.29).docx	Form and Instruction
Attachment R3_Parental Consent_(2022.02.23).docx NYTS Cognitive Testing Parent/ Guardian Consent	IC Document
Attachment R3_Parental Consent_(2022.02.23).docx NYTS Cognitive Testing Parent/ Guardian Consent	IC Document
Attachment R6_Youth Consent_(2022.03.21).docx Parent/Guardian Email and Youth Informed Consent for Cognitive Interviews	IC Document
Attachment R6_Youth Consent_(2022.03.21).docx Parent/Guardian Email and Youth Informed Consent for Cognitive Interviews	IC Document
Attachment R1_Cognitive Testing Protocol (2022.03.21).docx NYTS Cognitive Testing Protocol	IC Document
Attachment R1_Cognitive Testing Protocol (2022.03.21).docx NYTS Cognitive Testing Protocol	IC Document
Attachment R7_Notice of Non-Selection_(2022.03.21).docx NYTS Cognitive Testing Notice of Non-Selection	IC Document
Attachment R7_Notice of Non-Selection_(2022.03.21).docx NYTS Cognitive Testing Notice of Non-Selection	IC Document
Attachment R8_Cognitive Guides_(2022.03.21).docx NYTS Cognitive Testing Guides	IC Document
Attachment R8_Cognitive Guides_(2022.03.21).docx NYTS Cognitive Testing Guides	IC Document
Attachment R8a_Cognitive Guide-Item Set 1_(2022.03.29).docx NYTS Interviewer Guide – Item Set 1	IC Document
Attachment R8a_Cognitive Guide-Item Set 1_(2022.03.29).docx NYTS Interviewer Guide – Item Set 1	IC Document
Attachment R8b_Cognitive Guide-Item Set 2_(2022.03.29).docx NYTS Interviewer Guide – Item Set 2	IC Document
Attachment R8b_Cognitive Guide-Item Set 2_(2022.03.29).docx NYTS Interviewer Guide – Item Set 2	IC Document
Attachment R8c_Cognitive Guide-Item Set 3_(2022.03.29).docx NYTS Interviewer Guide – Item Set 3	IC Document
Attachment R8c_Cognitive Guide-Item Set 3_(2022.03.29).docx NYTS Interviewer Guide – Item Set 3	IC Document
Attachment R4_Youth Screener Invite_(2022.03.21).docx NYTS Cognitive Testing Invitation to Youth Screener	IC Document
Attachment R4_Youth Screener Invite_(2022.03.21).docx NYTS Cognitive Testing Invitation to Youth Screener	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Cognitive Testing

Agency IC Tracking Number:

0920-0621-22DZ

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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			Cognitive Testing for NYTS.docx	No		Fillable Fileable
Form and Instruction	0920-0621	NYTS Cognitive Testing Parent/ Guardian Screener	Attachment R2_NYTS Cog Testing Parent Screener_(2022.03.29).docx	Yes	Yes	Fillable Fileable
Form and Instruction	0920-0621	NYTS Cognitive Testing Youth Screener	Attachment R5_NYTS Cog Testing Youth Screener_(2022.03.29).docx	Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 40

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	Previously Approved
Annual Number of Responses for this IC	40	40
Annual IC Time Burden (Hours)	80	80
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
NYTS Cognitive Testing Parent/ Guardian Consent	Attachment R3_Parental Consent_(2022.02.23).docx	03/23/2022
Parent/Guardian Email and Youth Informed Consent for Cognitive Interviews	Attachment R6_Youth Consent_(2022.03.21).docx	03/23/2022
NYTS Cognitive Testing Protocol	Attachment R1_Cognitive Testing Protocol (2022.03.21).docx	03/23/2022
NYTS Cognitive Testing Notice of Non-Selection	Attachment R7_Notice of Non-Selection_(2022.03.21).docx	03/23/2022
NYTS Cognitive Testing Guides	Attachment R8_Cognitive Guides_(2022.03.21).docx	03/23/2022
NYTS Interviewer Guide â Item Set 1	Attachment R8a_Cognitive Guide-Item Set 1_(2022.03.29).docx	04/05/2022
NYTS Interviewer Guide â Item Set 2	Attachment R8b_Cognitive Guide-Item Set 2_(2022.03.29).docx	04/05/2022
NYTS Interviewer Guide â Item Set 3	Attachment R8c_Cognitive Guide-Item Set 3_(2022.03.29).docx	04/05/2022
NYTS Cognitive Testing Invitation to Youth Screener	Attachment R4_Youth Screener Invite_(2022.03.21).docx	04/05/2022

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