Information Collection

[NCHS] Direct Care Worker Pilot Study

IC 260303 under ICR 202212-0920-005 · OMB 0920-1030.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Director Sampling Appointment Setting Call [NCHS] Direct Care Worker Pilot Study	Form and Instruction
Director DCS Sampling Call [NCHS] Direct Care Worker Pilot Study	Form and Instruction
DCW Draft Question List [NCHS] Direct Care Worker Pilot Study	Form and Instruction
Director Sampling Appointment Setting Call Att B-1 Director Sampling Appointment Setting Call 5.11.23_final.docx	Form and Instruction
Director DCS Sampling Call Att B-3 Director DCW Sampling Call 5.11.23_final.docx	Form and Instruction
DCW Draft Question List Att C DCW draft question List 5.11.23_final.docx	Form and Instruction
Att A-1 Director mailing NCHS Cover Letter with FAQs 5.17.23.docx Director Mailing Cover Letter with FAQs	IC Document
Att A-2 DCW NCHS Cover Letter with FAQs 5.17.23.docx DCW Mailing Cover Letter with FAQs	IC Document
Att A-3 NCHS Strictly Confidential Brochure 5.11.23.docx Strictly Confidential Brochure	IC Document
Att B-2 CATI Confirmation and Prep Letter or email.docx CATI Confirmation and Prep Letter/Email	IC Document
Att D-1 Thank You Reminder letters 5.17.23.docx Thank You Reminder Letters	IC Document
Att D-2 Prompting emails 5.17.23.docx Prompting Letters	IC Document
Att E Human Subjects Determination 5.17.23.docx Human Subjects Determination	IC Document
NPALS DCW Pilot Supp State A_5.16.23_final.docx SSA	IC Document
NPALS DCW Pilot Supp State B_5.16.23.docx SSB	IC Document

IC Title:

Agency IC Tracking Number:

0920-1030-23FI

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	n/a	No		Fillable Fileable
Form and Instruction	n/a	No		Fillable Fileable
Form and Instruction	n/a	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: Health Resources Utilization Statistics

FR Citation: 59 FR 48331

Number of Respondents: 1,440

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 40 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,440	1,440
Annual IC Time Burden (Hours)	480	480
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Director Mailing Cover Letter with FAQs		05/22/2023
DCW Mailing Cover Letter with FAQs		05/22/2023
Strictly Confidential Brochure		05/22/2023
CATI Confirmation and Prep Letter/Email		05/22/2023
Thank You Reminder Letters		05/22/2023
Prompting Letters		05/22/2023
Human Subjects Determination		05/22/2023
SSA		05/22/2023
SSB		05/22/2023

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

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