[NCHS] Collaborating Center for Questionnaire Design and Evaluation Research

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 0920-0222 (25BG) Cognitive Interviewing Telephone Screening Script	Form and Instruction	New	Repair queued
Form 0920-0222 (25BG) Respondent Data Collection Sheet	Form and Instruction	New	Repair queued
Form 0920-0222 (25BG) Focus Group Telephone Screening Script	Form and Instruction	New	Repair queued
Form 0920-0222 (25BG) Focus Grouip Protocol	Form and Instruction	New	Repair queued
RANDS 11 Questionnaire-12.10.2024	Form and Instruction	New	Repair queued
Form 0920-24IT Respondent Informed Consent	Form	New	Repair queued
Form 0920-24IT Respondent Data Collection	Form	New	Repair queued
Form 0920-0222 Respondent Data Collection Sheet	Form and Instruction	New	Repair queued
Form 0920-0222 Questions to be Cognitively Tested	Form and Instruction	New	Repair queued
Form 0920-0222 Cognitive Decline - Screening Script	Form and Instruction	New	Repair queued
Form 0920-0222 Attachment 5 Informed Consent ADHD	Form and Instruction	New	Repair queued
Form 0920-0222 ADHD Attachment 1 Questions to be tested	Form and Instruction	New	Repair queued
Form 0920-0222 Attachment 6 Respondent Data Collection Sheet	Form and Instruction	New	Repair queued
Data Collection Sheets	Form and Instruction	New	Repair queued
Interviewer's Guide	Form and Instruction	New	Repair queued
Telephone Screening Script	Form and Instruction	New	Repair queued
Cannabis Data Collection Sheet	Form and Instruction	New	Repair queued
Cannabis Screening Script	Form and Instruction	New	Repair queued
Cannabis Questions to be Cognitively Tested	Form and Instruction	New	Repair queued
Form 0920-0222 (24CL) Respondent Data Collection Sheet	Form and Instruction	New	Repair queued
Form 0920-022 (24CL) Telephone Screening Script	Form	New	Repair queued
Form 0920-0222 CCQDER RANDS 10 Questionnaire	Form	New	Repair queued
Form 0920-24BI Attachment 3a- NHANES English Advertisement	Form and Instruction	New	Repair queued
Form 0920-24BI Attachment 5a & 5b - Informed Consent NHANES 11.16.23	Form and Instruction	New	Repair queued
Form 0920-24BI Attachment 4b- Screening script NHANES 11.16.23 CLEAN	Form and Instruction	New	Repair queued
Form 0920-24BI Attachment 4a - Screening script NHANES 11.16.23 CLEAN	Form and Instruction	New	Repair queued
Form 0920-24BI Attachment 1b-NHANES Question Set 2 11.22.23 CLEAN	Form and Instruction	New	Repair queued
Form 0920-24BI Attachment 1a-NHANES Question Set 1 11.16.23 CLEAN	Form and Instruction	New	Repair queued
Form 0920-0222 {NISVS] Respondent Data Collection Sheet (No Form)	Form	New	Repair queued
Form 0920-0222 NISVS Questionnaire	Form and Instruction	New	Repair queued
Form 0920-0222 NISVS Screener	Form and Instruction	New	Repair queued
Form 1 qustionnaire	Form and Instruction	New	Repair queued
Form 0920-0222-23EQ Screening Script	Form and Instruction	New	Repair queued
Form 0920- 0222-23EQ Questions	Form and Instruction	New	Repair queued
Form 0920-0222-23EQ Attachment 5a-5b Respondent Data Collection Sheet 4.28.23	Form and Instruction	New	Repair queued
Respondent Data Collection Sheet	Form and Instruction	New	Repair queued
Caregiving Screening Script	Form and Instruction	New	Repair queued
Caregiving Questions	Form and Instruction	New	Repair queued
Form 0920-0222-23EC RANDS 8 Questionnaire	Form and Instruction	New	Available
Att B 60-Day Published FRN 9_30_2022.pdf	Supplementary Document	Uploaded 2022-12-14	Repair queued
SSB_0222_12012022.docx	Supporting Statement B	Uploaded 2022-12-02	Repair queued
SSA_0222-12012022.docx	Supporting Statement A	Uploaded 2022-12-02	Repair queued
Att O Thank You Letter.docx	Supplementary Document	Uploaded 2021-08-03	Repair queued
Att N Explain Cog Interview.docx	Supplementary Document	Uploaded 2021-08-03	Repair queued
Att M Sample Resp Data Collect Sheet.docx	Supplementary Document	Uploaded 2021-08-03	Repair queued
Att L Sample Advance Letter.docx	Supplementary Document	Uploaded 2021-08-03	Repair queued
Att K Voice mail script.docx	Supplementary Document	Uploaded 2021-08-03	Repair queued
Att J Sample newspaper adv.docx	Supplementary Document	Uploaded 2021-08-03	Repair queued
Att I Sample flyer.docx	Supplementary Document	Uploaded 2021-08-03	Repair queued
Att H-1&H-2 IRB Approval Documentation.docx	Supplementary Document	Uploaded 2021-08-03	Repair queued
Att G Spec Consent Focus Group.docx	Supplementary Document	Uploaded 2021-08-03	Repair queued
Att F Spec Consent Cog Int.docx	Supplementary Document	Uploaded 2021-08-03	Repair queued
Att E Informed Consent.docx	Supplementary Document	Uploaded 2021-08-03	Repair queued
Att D Screening Script.docx	Supplementary Document	Uploaded 2021-08-03	Repair queued
Att C Nondisclosure Affidavit.docx	Supplementary Document	Uploaded 2021-08-03	Repair queued
Att A Public Health Serv Act.docx	Supplementary Document	Uploaded 2021-08-03	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
272342	[NCHS] 2024 NHIS Diabetes	Form and Instruction	New	Cognitive Interviewing Telephone Screening Script
272342	[NCHS] 2024 NHIS Diabetes	Form and Instruction	New	Respondent Data Collection Sheet
272342	[NCHS] 2024 NHIS Diabetes	Form and Instruction	New	Focus Group Telephone Screening Script
272342	[NCHS] 2024 NHIS Diabetes	Form and Instruction	New	Focus Grouip Protocol
272296	[NCHS] Collaborating Center for Questionnaire Design and Evaluation Research - RANDS 11	Form and Instruction	New	RANDS 11 Questionnaire-12.10.2024
271058	[NCHS] BMI Focus Groups	Form	New	Respondent Informed Consent
271058	[NCHS] BMI Focus Groups	Form	New	Respondent Data Collection
269389	CCQDER - Questions on Subjective Cognitive Decline	Form and Instruction	New	Respondent Data Collection Sheet
269389	CCQDER - Questions on Subjective Cognitive Decline	Form and Instruction	New	Questions to be Cognitively Tested
269389	CCQDER - Questions on Subjective Cognitive Decline	Form and Instruction	New	Cognitive Decline - Screening Script
266008	[NCHS] genIC Attention Deficient Hyperactivity Disorder Questions	Form and Instruction	New	Attachment 5 Informed Consent ADHD
266008	[NCHS] genIC Attention Deficient Hyperactivity Disorder Questions	Form and Instruction	New	ADHD Attachment 1 Questions to be tested
266008	[NCHS] genIC Attention Deficient Hyperactivity Disorder Questions	Form and Instruction	New	Attachment 6 Respondent Data Collection Sheet
265792	[NCHS] Point of Care Checklist Subproject 1: Conducting In-depth Interviews Among Those with Intellectual and Developmental Disabilities	Form and Instruction	New	Data Collection Sheets
265792	[NCHS] Point of Care Checklist Subproject 1: Conducting In-depth Interviews Among Those with Intellectual and Developmental Disabilities	Form and Instruction	New	Interviewer's Guide
265792	[NCHS] Point of Care Checklist Subproject 1: Conducting In-depth Interviews Among Those with Intellectual and Developmental Disabilities	Form and Instruction	New	Telephone Screening Script
264921	[NCHS] Evaluation of Revised Questions on Cannabis Use and Experiences	Form and Instruction	New	Cannabis Data Collection Sheet
264921	[NCHS] Evaluation of Revised Questions on Cannabis Use and Experiences	Form and Instruction	New	Cannabis Screening Script
264921	[NCHS] Evaluation of Revised Questions on Cannabis Use and Experiences	Form and Instruction	New	Cannabis Questions to be Cognitively Tested
264723	[NCHS] RANDS 10 and Accompanying Cognitive Interviews (24CL)	Form and Instruction	New	Respondent Data Collection Sheet
264723	[NCHS] RANDS 10 and Accompanying Cognitive Interviews (24CL)	Form	New	Telephone Screening Script
264723	[NCHS] RANDS 10 and Accompanying Cognitive Interviews (24CL)	Other-Proposed Questions	New
264723	[NCHS] RANDS 10 and Accompanying Cognitive Interviews (24CL)	Form	New	CCQDER RANDS 10 Questionnaire
264394	[NCHS]CCQDER's NHANES Feeding Practices	Form and Instruction	New	Attachment 3a- NHANES English Advertisement
264394	[NCHS]CCQDER's NHANES Feeding Practices	Form and Instruction	New	Attachment 5a & 5b - Informed Consent NHANES 11.16.23
264394	[NCHS]CCQDER's NHANES Feeding Practices	Form and Instruction	New	Attachment 4b- Screening script NHANES 11.16.23 CLEAN
264394	[NCHS]CCQDER's NHANES Feeding Practices	Form and Instruction	New	Attachment 4a - Screening script NHANES 11.16.23 CLEAN
264394	[NCHS]CCQDER's NHANES Feeding Practices	Form and Instruction	New	Attachment 1b-NHANES Question Set 2 11.22.23 CLEAN
264394	[NCHS]CCQDER's NHANES Feeding Practices	Form and Instruction	New	Attachment 1a-NHANES Question Set 1 11.16.23 CLEAN
263924	[NCHS] CCQDER - NISVS	Form	New	{NISVS] Respondent Data Collection Sheet (No Form)
263924	[NCHS] CCQDER - NISVS	Form and Instruction	New	NISVS Questionnaire
263924	[NCHS] CCQDER - NISVS	Form and Instruction	New	NISVS Screener
262818	GenIC for CCQDER's RANDS 9	Form and Instruction	New	qustionnaire
260045	[NCHS] COLLABORATING CENTER FOR QUESTIONNAIRE DESIGN AND EVALUATION RESEARCH	Form and Instruction	New	Screening Script
260045	[NCHS] COLLABORATING CENTER FOR QUESTIONNAIRE DESIGN AND EVALUATION RESEARCH	Form and Instruction	New	Questions
260045	[NCHS] COLLABORATING CENTER FOR QUESTIONNAIRE DESIGN AND EVALUATION RESEARCH	Form and Instruction	New	Attachment 5a-5b Respondent Data Collection Sheet 4.28.23
260017	[NCHS] CCQDER's Caregiver	Form and Instruction	New	Respondent Data Collection Sheet
260017	[NCHS] CCQDER's Caregiver	Form and Instruction	New	Caregiving Screening Script
260017	[NCHS] CCQDER's Caregiver	Form and Instruction	New	Caregiving Questions
259654	[NCHS] Collaborating Center For Questionnaire Design and Evaluation Research	Form and Instruction	New	RANDS 8 Questionnaire

ICR Details

OMB Control No: 0920-0222	ICR Reference No: 202212-0920-003
Status: Historical Active	Previous ICR Reference No: 202107-0920-010
Agency/Subagency: HHS/CDC	Agency Tracking No: 0920-0222
Title: [NCHS] Collaborating Center for Questionnaire Design and Evaluation Research
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 01/27/2023
Retrieve Notice of Action (NOA)	Date Received in OIRA: 12/21/2022
Terms of Clearance: : CDC will continue to submit individual collections under this generic clearance to OMB. OMB will strive to provide feedback on the individual collections within ten working days, whenever possible, as is currently the case.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2026	36 Months From Approved	09/30/2024
Responses	215,775	0	66,375
Time Burden (Hours)	65,715	0	28,365
Cost Burden (Dollars)	1,840,677	0	255,947

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Abstract: This generic clearance request encompasses general questionnaire development, pre-testing, measurement-error reduction activities to be carried out in 2021-2024 in the Division of Research and Methodology, National Center for Health Statistics (NCHS), Centers for Disease Control and Prevention (CDC). The revision request consists of an increase in burden hours for the next 3-year approval period due to an anticipated increase in the number of RANDS Methodological projects during the approval period.

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Authorizing Statute(s): US Code: 42 USC 242k Name of Law: Public Health Service Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	87 FR 59425	09/30/2022
30-day Notice:	Federal Register Citation:	Citation Date:
	87 FR 76049	12/12/2022
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 14

table that charts list of burden

IC Title	Form No.	Form Name
CCQDER - Questions on Subjective Cognitive Decline	0920-0222, 0920-0222, 0920-0222	Cognitive Decline - Screening Script ,   Questions to be Cognitively Tested ,   Respondent Data Collection Sheet
GenIC for CCQDER's RANDS 9	1	qustionnaire
[NCHS] 2024 NHIS Diabetes	0920-0222 (25BG), 0920-0222 (25BG), 0920-0222 (25BG), 0920-0222 (25BG)	Focus Grouip Protocol ,   Focus Group Telephone Screening Script ,   Respondent Data Collection Sheet ,   Cognitive Interviewing Telephone Screening Script
[NCHS] BMI Focus Groups	0920-24IT, 0920-24IT	Respondent Data Collection ,   Respondent Informed Consent
[NCHS] CCQDER - NISVS	0920-0222, 0920-0222, 0920-0222	NISVS Screener ,   NISVS Questionnaire ,   {NISVS] Respondent Data Collection Sheet (No Form)
[NCHS] CCQDER's Caregiver	n/a, n/a, n/a	Caregiving Questions ,   Caregiving Screening Script ,   Respondent Data Collection Sheet
[NCHS] COLLABORATING CENTER FOR QUESTIONNAIRE DESIGN AND EVALUATION RESEARCH	0920-0222-23EQ, 0920- 0222-23EQ, 0920-0222-23EQ	Attachment 5a-5b Respondent Data Collection Sheet 4.28.23 ,   Questions ,   Screening Script
[NCHS] Collaborating Center For Questionnaire Design and Evaluation Research	0920-0222-23EC	RANDS 8 Questionnaire
[NCHS] Collaborating Center for Questionnaire Design and Evaluation Research - RANDS 11	n/a	RANDS 11 Questionnaire-12.10.2024
[NCHS] Evaluation of Revised Questions on Cannabis Use and Experiences	n/a, n/a, n/a	Cannabis Questions to be Cognitively Tested ,   Cannabis Screening Script ,   Cannabis Data Collection Sheet
[NCHS] Point of Care Checklist Subproject 1: Conducting In-depth Interviews Among Those with Intellectual and Developmental Disabilities	n/a, n/a, n/a	Telephone Screening Script ,   Interviewer's Guide ,   Data Collection Sheets
[NCHS] RANDS 10 and Accompanying Cognitive Interviews (24CL)	0920-0222 (24CL), 0920-0222, 0920-022 (24CL)	CCQDER RANDS 10 Questionnaire ,   Telephone Screening Script ,   Respondent Data Collection Sheet
[NCHS] genIC Attention Deficient Hyperactivity Disorder Questions	0920-0222, 0920-0222, 0920-0222	Attachment 6 Respondent Data Collection Sheet ,   ADHD Attachment 1 Questions to be tested ,   Attachment 5 Informed Consent ADHD
[NCHS]CCQDER's NHANES Feeding Practices	0920-24BI, 0920-24BI, 0920-24BI, 0920-24BI, 0920-24BI, 0920-24BI	Attachment 1a-NHANES Question Set 1 11.16.23 CLEAN ,   Attachment 1b-NHANES Question Set 2 11.22.23 CLEAN ,   Attachment 4a - Screening script NHANES 11.16.23 CLEAN ,   Attachment 4b- Screening script NHANES 11.16.23 CLEAN ,   Attachment 5a & 5b - Informed Consent NHANES 11.16.23 ,   Attachment 3a- NHANES English Advertisement

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ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	215,775	66,375	0	149,400	0	0
Annual Time Burden (Hours)	65,715	28,365	0	37,350	0	0
Annual Cost Burden (Dollars)	1,840,677	255,947	0	1,584,730	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: Revision for 0920-0222 requests an increase in burden hours for the next 3-year approval period due to an anticipated increase in the number of RANDS Methodological projects during the approval period.

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Annual Cost to Federal Government: $3,223,325

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 12/21/2022

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