0920-0950 SSA Revised 2025APR16

Supporting Statement A

Request for Clearance

National Health and Nutrition Examination Survey

OMB No. 0920-0950

Expiration Date: 04/30/2025

Contact Information:

David Woodwell, MPH

Chief, Planning Branch

Division of Health and Nutrition Examination Surveys

National Center for Health Statistics/CDC

3311 Toledo Road

Hyattsville, MD 20782

Telephone: 301-458-4327

FAX: 301-458-4028

February 14, 2025

tABLE OF CONTENTS

Section	page
A. Justification...............................................................................................................................................	7
1. Circumstances Making the Collection of Information Necessary............................................................	7
2. Purpose and Use of the Information Collection.......................................................................................	7
3. Use of Information Technology and Burden Reduction...........................................................................	18
4. Efforts to Identify Duplication and Use of Similar Information..................................................................	18
5. Impact on Small Businesses or Other Small Entities...............................................................................	18
6. Consequences of Collecting the Information Less Frequently ...............................................................	19
7. Special Circumstances Relating to the Guidelines of 5 CFR 1320.5.......................................................	19
8. Comments in Response to the Federal Register Notice and Efforts to Consult Outside the Agency......	19
9. Explanation of Any Payment or Gift to Respondents...............................................................................	20
10. Protection of the Privacy and Confidentiality of Information Provided by Respondents.........................	22
11. Ethical Review Board (ERB) and Justification for Sensitive Questions..................................................	27
12. Estimates of Annualized Burden Hours and Costs..................................................................................	30
13. Estimate of Other Total Annual Cost Burden to Respondents and Record Keepers..............................	33
14. Annualized Cost to the Federal Government...........................................................................................	33
15. Explanation for Program Changes or Adjustments..................................................................................	33
16. Plans for Tabulation and Publication and Project Time Schedule...........................................................	33
17. Reason(s) Display of OMB Expiration Date is Inappropriate...................................................................	34
18. Exceptions to Certification for Paperwork Reduction Act Submissions...................................................	34
19. Appendix A: 2025-2026 NHANES Added Questions and Validation/Justification………………………...	35

Attachment List

Attachment 1	Applicable Laws or Regulations (Excerpts)
Attachment 2a	60-Day Federal Register Notice
Attachment 2b	60-day FRN Comments
Attachment 2c	NCHS’ Responses to the Comments
Attachment 3	Protocol Changes from Previous Cycle
Attachment 4	Sample Design Tables 2025-2026
Attachment 5	Summary of Questionnaire Changes in 2025-2026
Attachment 6a	Household Screener Questionnaire
Attachment 6b	Survey Participant Questionnaire
Attachment 6c	Household Questionnaire
Attachment 6d	Water Collection Protocol
Attachment 6e	Home Interview Hand Cards
Attachment 6f	MEC and Dietary Recruitment and Scheduling Instrument
Attachment 6g	MEC Examination and Interview Data Collection Forms
Attachment 6h	MEC Exam Hand Cards
Attachment 6i	Dietary Front End Instrument
Attachment 6j	Dietary Interview Day 1 Instrument
Attachment 6k	Dietary Interview Day 2 Instrument
Attachment 6l	Dietary Incentive and Scheduling Instrument
Attachment 6m	Flexible Consumer Behavior Survey Instrument
Attachment 6n	Dietary Interview Hand Cards
Attachment 6o	MEC and Dietary Reminder Call Instrument
Attachment 7	Developmental Project Report – Child Blood Pressure
Attachment 8	Laboratory Assessments 2025-2026 and earlier
Attachment 9	Agencies Consulted 2025-2026
Attachment 10	NHANES History
Attachment 11a	Advance Household Letter
Attachment 11b	Consent Materials
Attachment 11c	Nonresponse Letters
Attachment 11d	Material Handouts
Attachment 11e	MEC Examination Materials
Attachment 11f	MEC Examination Results
Attachment 11g	Dietary Interview Materials
Attachment 12	ERB Approval
Attachment 13	Developmental Projects & Special Studies

Supporting Statement A

National Center for Health Statistics (NCHS)

National Health and Nutrition Examination Survey (NHANES)

• The goal of the study is to assess the health and nutritional status of adults, adolescents, and children in the United States.

• The intended use of the resulting data is to monitor public health and promote health by preventing and controlling disease and disability.

• The method to be used is a cross-sectional survey employing a stratified, multistage area probability sample design.

• The population to be studied is a nationally representative sample of the civilian, non-institutionalized U.S. population, all ages.

• The data will be analyzed using appropriate statistical approaches and models.

This request is for a revision to the National Health and Nutrition Examination Survey (NHANES) (OMB No. 0920-0950, Exp. Date 04/30/2025). The Division of Health and Nutrition Examination Surveys (DHNES), also referred to as the Program, is requesting a 3-year clearance. Nonsubstantive change requests will be submitted to request approval to make subsequent minor modifications to the questionnaire(s) and to conduct methodological testing.

The National Center for Health Statistics (NCHS) of the Centers for Disease Control and Prevention (CDC) conducts the NHANES. This survey is a major ongoing source of information on the health and nutritional status of the civilian, non-institutionalized population of the United States.

The Program is submitting this revision request to:

• Collect data in years 2025-2026;

• Collect follow-up data and conduct activities related to data collection/processing (for survey year 2026) through 2027;

• Conduct developmental projects to support data collection for 2027 and beyond; and

• Conduct nonresponse projects as needed.

Brief Summary of Planned Changes for the 2025-2026 NHANES

This request includes obtaining clearance to conduct NHANES Survey Participant (SP) and household interviews; dietary interviews; Mobile Examination Center (MEC) interviews; the NHANES examination; laboratory assessments; and other follow-up activities for 2025–2026.

The Program paused data collection following the August 2021–August 2023 data collection to update the survey and modernize processes for 2025–2026 data collection. These changes impact a broad range of survey areas, such as design and construction of a new fleet of MECs, sample design (discussed in section 1. Respondent Universe and Sampling Methods - Supporting Statement B), operational procedures (e.g., interview and examination protocols and MEC hours), NHANES content (questionnaires, exam components, and laboratory measures), and outreach materials. These design modifications will result in improvements in precision and reductions in burden. A high-level summary of changes from the August 2021–August 2023 data collection cycle to the 2025–2026 cycle is provided in Attachment 3. Because of these changes, NHANES 2025–2026 may or may not be comparable with previous NHANES cycles. However, the 2025–2026 data collection will continue with a single-year nationally representative sample as outlined in Table 1. The NHANES data will still likely be released in 2-year cycles to create more stable estimates than would be possible with one-year estimates, and to protect participant confidentiality. The Program consulted with collaborators, stakeholders, and the NCHS Board of Scientific Counselors to communicate and seek input on changes under consideration.¹

Table 1. Details of the Sample Design by Cycle 

Data Collection Cycle	Sample Design
1999–2018	Each single year is nationally representative.  Any combination of consecutive years is nationally representative.
2019–2020	Each single year is NOT nationally representative.  This change was made to increase operational efficiency, which:  allowed the MECs to stay in one location longer, providing time for more screening and interviewing; and  reduced the travel distance of the MECs by allowing them to stay in one region of the country in a given year versus crisscrossing the country. Nationally representative when combined with 2017-2018 data.2  Because the survey was paused in March 2020, new content in 2019–2020 is only available on a convenience sample through restricted access.  Content in 2019–2020 that was also collected in previous cycles of NHANES was made publicly available in a merged 2017–March 2020 pre-pandemic data file.
August 2021–August 2023	Each single year from August to August is nationally representative.  Any combination of consecutive years is nationally representative.
2025–2026	Each single year will continue to be nationally representative.

NHANES is collecting data on a single-year, nationally representative sample of 5,000 people during 2025–2026, oversampling children 0-17 years of age, persons 65 years of age and older, and non-Hispanic Black people. NHANES continues to consider the reduction in ability to generalize about smaller sociodemographic groups and consider options for studies that provide valuable data for populations hit particularly hard by the COVID-19 pandemic. Sample design changes are discussed in greater detail in Supporting Statement B and Attachment 4.

Adding/modifying in 2025–2026:

• The Program revised the Household Questionnaire to collect information at the household level instead of the family unit.

• The Program revised the Survey Participant Questionnaire to include sections previously administered during the MEC exam for SPs 18 years of age and older.

• The Program reduced questions in the Flexible Consumer Behavior Survey (FCBS) component and presented these questions at a different point during the dietary interview.

• The Body Composition examination will modify dual energy x-ray absorptiometry (DXA) from a whole-body scan to bone density measurement of hip and spine only. The spine and hip scans were last included in 2018.

• The Respiratory Health examination will cycle back spirometry, which was last included in 2012.

• The Audiometry examination will cycle back in and was last included in 2020.

• The Visual Acuity and Ophthalmology examinations will cycle back in and were last included in 2008.

• The Oral Health examination will cycle back in and was last included in 2020.

• Oral rinse sample for human papilloma virus (HPV) analyses is cycling back into the survey (14–64 years of age) and was last included in 2016.

• HPV DNA swab collection is cycling back in and was last included in 2020.

• Home water sample collection is cycling back in to measure fluoridation. This component was last included in 2020.

• The Program modified multiple questionnaire and laboratory components.

Cycling out of NHANES 2025–2026:

• Liver elastography and liver genetics

• Urine testing for Chlamydia trachomatis, Trichomonas vaginalis, and Mycoplasma genitalium. Serology testing for HIV, COVID-19, Herpes Simplex 1&2, HPV and cytomegalovirus (CMV) antibodies

• Dioxins

• RBC Folate Forms and RBC Fatty Acids

Please find a summary of changes to the questionnaires in Attachment 5. In Appendix A of this supporting statement, the Program has provided a comprehensive table of added questions, justifications for inclusion, and methods of validation. Although questions may not have undergone cognitive testing, they were developed based on recommendations from subject matter experts across government agencies and/or taken directly from previous national survey instruments.

NHANES will continue to submit requests to conduct future developmental projects (i.e., pilot, feasibility or special studies testing methodologies, equipment, or other developmental projects through nonsubstantive change requests, generic information collection requests (GenICRs), or full revisions, as appropriate. These projects could include NHANES participants (present or past), members of the health care community (such as records retrieval staff, or health care providers) and volunteers (non-NHANES participants) who may receive remuneration or tokens of appreciation.

NHANES anticipates that the first public release of some NHANES 2025–2026 data will occur by September 2027. Every effort is being made to reduce the length of time for making NHANES data available to the public. 

A. Justification

1. Circumstances Making the Collection of Information Necessary

Authorization 

Four public laws authorize or necessitate the collection of information about the health of the American people. Excerpts of these laws are in Attachment 1.

1. Section 306 of the Public Health Service Act (42 U.S.C. 242k), which directs NCHS to collect statistics on subjects, such as the extent and nature of illness and disability of the population; environmental, social, and other health hazards; determinants of health; health resources; and utilization of health care.

2. Section 4403 (Joint Nutrition Monitoring and Related Research Activities) of the Food, Conservation, and Energy Act of 2008 (P.L. 110-234) specifies that the Secretary of Health and Human Services shall continue to provide jointly for national nutrition monitoring and related research activities carried out as of the date of enactment of this Act. 

3. The Food Quality Protection Act of 1996 (P.L. 104-170), which requires the implementation of surveys to collect data on food consumption patterns of infants and children and data on dietary exposure to pesticides among infants and children.

4. The Federal Food, Drug, and Cosmetic Act (21 USC 393), Chapter 9, which authorizes the collection of information to support the Food and Drug Administration’s objective to obtain current, timely, and policy-relevant consumer information to carry out its statutory functions.

2. Purpose and Use of the Information Collection

The NHANES August 2021–August 2023 data collection ended in August 2023. The Program paused data collection until the 2025–2026 cycle to modernize the survey and processes.

The major objectives of NHANES are to: 

1. estimate the number and percentage of persons in the U.S. population and designated subgroups with selected diseases and risk factors; 

2. monitor trends in the prevalence, awareness, treatment, and control of selected diseases; 

3. monitor trends in risk behaviors and environmental exposures; 

4. analyze risk factors for selected diseases;

5. study the relationship between diet, nutrition, and health; 

6. explore emerging public health issues and new technologies; 

7. establish and maintain a national probability sample of baseline information on health and nutritional status; 

8. collect and maintain a national probability sample of serum, plasma, and urine biospecimens for potential future public health use and surveillance; and

9. collect and maintain a national probability sample of DNA specimens for potential future public health use and surveillance.

Under Section 2c(ii) of Executive Order on Ensuring an Equitable Pandemic Response and Recovery, it states:

(c) Data Collection. To address the data shortfalls identified in section 1 of this order, and consistent with applicable law, the Task Force shall: 

(i) develop, in collaboration with the heads of relevant agencies, a set of longer-term recommendations to address these data shortfalls and other foundational data challenges, including those relating to data intersectionality, that must be tackled in order to better prepare and respond to future pandemics. 

NHANES 2025–2026 is oversampling children (0–17 years of age) and older persons (65 years of age and over). Additionally non-Hispanic Black people will be oversampled. See Section 1 of Supporting Statement B for details. 

NHANES consists of three primary methods of data collection: the personal interviews, the examination, and the laboratory assessments. Results from 2025–2026 NHANES will be used to assess current health measures in the U.S. population.

NHANES Interviews 

We collect questionnaire data as standalone components or to complement one or more examination or laboratory assessments. For NHANES 2025–2026, screening and interviews will be conducted via in-person interview in the home and by telephone. The NHANES interviews consist of the following major components: 

1. Household Screener Questionnaire (determines eligibility) (SCQ)

2. Survey Participant Questionnaire (SPQ) 

3. Household Questionnaire (HQ) 

4. MEC Interview Questionnaire (Post consent, MEC CAPI (computer-assisted personal interview [CAPI]) and MEC ACASI (audio computer-assisted self-interview [ACASI])) 

5. Telephone Dietary Interview Day 1 (24-Hour Dietary Recall, Dietary Supplements, and Post-Dietary Recall Questions, Flexible Consumer Behavior Survey) 

6. Telephone Dietary Interview Day 2 (24-Hour Dietary Recall, Dietary Supplements and Post-Dietary Recall Questions) 

A summary of the changes in questionnaires by administration modes between NHANES August 2021–August 2023 and 2025–2026 are provided in Table 2. Interviews were modified or shortened to reduce respondent burden.

Table 2. Modes of Data Collection

Order	Questionnaire	August 2021-August 2023	2025-2026
1	Household Screener	Multimode	In-person
2	Survey Participant (SP) & Household Questionnaires	Telephone & In-person	In-person, some ACASI
3	MEC Interview Questionnaire: Post Consent, CAPI, and ACASI Interviews	Primarily ACASI	In-person, some ACASI
4	First Dietary Recall	Telephone (post MEC)	Telephone (pre- or post-MEC)
5	Flexible Consumer Behavior Survey	Telephone  (post MEC)	Telephone, conducted following First Dietary Recall (pre- or post-MEC)
6	Second Dietary Recall	Telephone  (post MEC)	Telephone (pre- or post-MEC)

NHANES staff conducted a thorough review of the questionnaire content and made changes to focus on retaining questions that are directly related to the interpretation of exam or lab data collected in the survey and relevant to assess other health topics. Further review of all data collection instruments was done to update wording, update age restrictions for the respondent universe, align wording across instruments, eliminate duplicate questions, improve interview flow, and reduce respondent burden. Attachment 5 provides a description of all questionnaire changes (including modifications). The complete set of 2025–2026 questionnaires and associated hand cards are in Attachments 6a-6o.

Below is a brief description of the major changes made to data collection instruments for this current cycle:

• The Household Screener Questionnaire was redesigned to streamline rostering individuals as a household. The relationship module was deleted, and interviewers will now collect first names only. Full names and contact information will only be collected for anyone selected to participate as either an SP, a proxy for an SP, or anyone designated to fill out the Household questionnaire (referred to as the Household Reference Person).

• All screening and interviewing during the household visit will be completed with an adult 18 years of age or older. Emancipated minors are no longer eligible to complete interviews on their own.

• The Survey Participant Questionnaire now includes sections previously administered during the MEC exam. These sections—reproductive health, bladder functioning, alcohol use, and depression—are administered via ACASI toward the end of the SP interview only for SPs who are 18 years of age and older. New sections were added to the Survey Participant Questionnaire about osteoporosis, respiratory health/allergies, vision, and infant formula. Sections on balance have been removed.

• The Household Questionnaire will collect information at the household level instead of the family level as was previously collected.

• The MEC ACASI Questionnaire will be administered to all SPs 12-64 years of age during the MEC visit. The section on current health status has been removed. For adolescents 12-17 years of age, the questionnaire will collect data on reproductive health, drug use, alcohol use, and depression.

Day 1 and Day 2 Dietary Interviews 

Prior to the COVID-19 pandemic, NHANES conducted an in-person dietary interview at the MEC (Day 1) and a second dietary interview by phone (Day 2). However, NHANES was approved to administer the two dietary interviews via telephone in the August 2021–August 2023 data collection to limit time respondents spend in the MEC which occurred at the end of the COVID-19 Pandemic. Dietary phone interviews occurred after the MEC exam and were found to be feasible. Travel cost by dietary interviewers was reduced as a result. Cost constraints will limit the MEC examination sessions to 2 hours in 2025. The average time to conduct in-person dietary interview was 24-34 minutes in 2017-2018, thus physical examinations would need to be eliminated in the MEC to allow time for the dietary interview if it were to occur in the MEC. Therefore, we plan to conduct the two dietary interviews by phone in 2025. Additionally, changes will be implemented to provide more flexibility in the timing to complete the interview.

• For August 2021–August 2023, when the participant went to the MEC for their examination, staff scheduled an appointment for the participant to be called 3-7 days later to complete the Day 1 Dietary Interview over the phone. A participant (or family, if more than one from a household) was given a Food Model Booklet and dietary kit to estimate portions consumed. At the end of the Day 1 Dietary Interview, the interviewer asked if they could schedule an appointment for a second dietary interview.

• For 2025–2026, after the participant completes the Survey Participant Questionnaire, they can schedule their Day 1 Dietary Interview. The Day 2 Dietary Interview is scheduled after completing the Day 1 interview. Both interviews can be completed before or after their MEC examination. If the participant does not schedule their dietary interview appointment(s) prior to their MEC examination, the MEC staff will attempt to schedule this appointment at the end of the examination.

Please find an overall summary of 2025–2026 changes to NHANES questionnaire content in Attachment 5. See Attachments 6a-6f for the screener and household interview, inclusive of the related hand cards. See Attachments 6g-6o for a summary of NHANES MEC questionnaires, exams and phone follow-up interviews (i.e., dietary recall and the FCBS), along with corresponding hand cards and appointment reminder call scripts. 

NHANES Examination 

NHANES continues to monitor trends in the prevalence and treatment of many conditions via data collected through physical examination, laboratory assays, and questionnaires conducted in five MECs.

Mobile Examination Centers

Each MEC consists of three 38-foot custom-built mobile vehicles, connected to create the one examination center. Each MEC will be established within each Primary Sampling Unit (PSU) to maximize SPs’ access. The MECs are furnished with all the medical equipment needed to maintain methodological stability from prior cycles and designed to ensure SP privacy and safety during each data collection procedure. One vehicle is specifically designed to process all the biospecimens and environmental specimens (e.g., fluoride in water) that are included in the 2025–2026 cycle. The MECs have also been designed to minimize the risk of infections while maximizing staff efficiency in collecting high-quality data.

The MECs for 2025–2026 differ from the previous cycle based on number, size, and mobility. NHANES is moving from a 52-foot trailer design to a 38-foot vehicle design (cab included) with expandable sides. Utilizing smaller vehicles will allow for more efficient relocation of the MECs between PSUs including ease and efficient setup. The new MECs can easily be moved and stationed in more than one location within a PSU. By moving the MECs closer to participants, the Program can minimize respondent burden, decrease travel costs to the exam, facilitate flexible scheduling, and increase response rates. The new MEC design allows for a smaller footprint with setup, and with expandable sides sophisticated engineering will create a data collection space that meets NHANES data collection needs, remaining consistent with prior cycles. The new design will include a central hallway with exam rooms on either side and start-to-finish flow through the MECs to maximize privacy for participants. Although updated models of specific equipment will be deployed (e.g., hemolyzer for CBC and DXA), crossover testing will occur to correlate data sets. The smaller size of the MECs will require more consistency in data collection procedures with a more streamlined scheduling scheme that allows one SP to be scheduled every 30-60 minutes. Additionally, the smaller size also requires fewer staff, which will improve flexibility in data collection while remaining adherent to protocol.

MEC Examinations

It should be noted that many auxiliary exams were significantly modified or eliminated when NHANES reentered the field in August 2021, following a cessation of operations because of the COVID-19 pandemic. In 2025-2026, many of these auxiliary exams will be reintroduced with some modification.

The following exam content continues in 2025–2026 with minimal or no change from previous NHANES cycles: 

• Post-consent questions, asked of all SPs via CAPI, have been updated to reflect changes to exams.

• Anthropometry (Body Measures) for all SPs. This exam will include sitting height and biacromial breadth and chest circumferences to support lung function testing (as described below). Upper leg length measurement will be removed.

• Oscillometer (Blood Pressure & Pulse) for all SPs 8 years of age and older. The pilot test to determine if blood pressure could be obtained from participants 3 to 7 years of age did not meet the study’s goals,³ and therefore oscillometer blood pressure measurements for SPs 3-7 years of age will not be obtained in 2025 (Attachment 7).

• Venipuncture will continue for all SPs 1 year of age and older. Specific changes to age inclusion categories and list of analytes to be tested are described below.

• Urine collection will continue for all SPs 3 years of age and older. Specific changes to age inclusion categories and list of analytes to be tested are described below.

• Questions from the phlebotomy exam have been separated out and included as a short questionnaire administered via CAPI right before administration of the MEC ACASI questionnaire. This short CAPI interview also includes a request for Social Security number for future data linkage for all SPs who did not provide this information earlier.

• MEC ACASI Questionnaire will continue for all SPs 12-64 years of age with adjustments to the content as described previously.

The following examination content has been added/modified for the 2025–2026 cycle⁴:

• Body Composition examination using DXA (modified)

• This exam will focus on proximal femur (hip) and the lumbar spine Bone Mineral Density and no longer includes whole-body scan. Only SPs 45 years of age and older will be eligible to participate in this exam.

• Respiratory Health examination (added)

• This exam will incorporate Lung Function measurements (via spirometry – last included in the 2011-2012 NHANES). SPs 5 years of age and older will be eligible to participate in spirometry.

• Audiometry examination (added)

• This exam, last administered in the 2017-March 2020 NHANES, incorporates similar elements as previously collected in NHANES with some modifications. The 2025 protocol is similar to the previous protocol but reflects adjustments to accommodate testing outside a sound booth. Audiometry items are included in the Survey Participant Questionnaire. In the MEC, staff will capture a digital image of the SP’s ear canal and tympanic membrane using a digital otoscope. This image will be electronically transferred and reviewed by subject matter experts at NIOSH. Acoustic immittance and middle ear function will be objectively measured via a tympanometer. Pure tone air conduction audiometry will also be conducted. All SPs 5-44 years of age are eligible to participate in the Audiometry examination.

• Visual Acuity and Ophthalmology examinations (added)

• These exams, which were both last administered in the 2007-2008 NHANES, will include an assessment of SPs’ visual acuity via the Topcon KR-800 autorefractor. The SP’s corrective prescription will be measured using a lensometer (Topcon CL-300). All SPs 6 years of age and older are eligible to participate in the vision acuity examination. All SPs 45 years of age and older, and SPs 18-44 years of age who reported history of diabetes, will be eligible to participate in the ophthalmology examination. Retinal images will be captured using the Topcon Maestro2 fully automated optical coherence tomography and true color fundus camera. Retinal images obtained will be electronically transferred and reviewed by a retinal image reading center systematically following a strict protocol.

• Oral Health examination (added)

• This exam was last included in the 2017-March 2020 NHANES. SPs 1 year of age and older are eligible for the dental examination assessment, which will include specific components depending on the age of the SP as listed below.

• Tooth loss (1+ years)

• Dental caries (1+ years)

• Dental sealants (2–17 years)

• Root caries (18+ years)

• Oral Rinse for Human Papilloma Virus (HPV) (added)

• This exam was last administered in the 2015-2016 NHANES. SPs 14-64 years of age are eligible to participate in the oral rinse exam, which will test for HPV. Samples will be tested for 37 HPV types in addition to HPV high and low globulin bands.

• HPV DNA Swab Collection (added)

• This exam component was last included in the 2017-March 2020 NHANES. All SPs 14-64 years of age will be provided instruction to self-collect a genital swab. The specimens will be tested for HPV types 6, 11, 16, 18, 31, 33, 45, 52, and 58.

• Fluoride in Water (added)

• As in prior years, fluoridation in household water will be measured for a subsample of the NHANES population. Because fluoridation is a particular concern during growth and development, NHANES will be collecting and measuring the household water fluoride concentration of selected dwelling units (DUs) with a household member 17 years of age or younger. This exam was last included in 2020.

Attachment 5 provides a description of all MEC questionnaire examination changes. See Attachment 6g for NHANES 2025–2026 MEC examination data collection forms. 

The following examination content was dropped: 

• Liver Elastography and liver genetics

• Urine testing for Chlamydia trachomatis, Trichomonas vaginalis, and Mycoplasma genitalium

• Serology testing for HIV, COVID-19 serology, Herpes Simplex 1&2, HPV and CMV antibodies

• Dioxins

• RBC Folate Forms and RBC Fatty Acids

• MEC Follow-up Questionnaires

NHANES Laboratory Assessments 

In 2025–2026, NHANES has added new lab content and modified age eligibility, which has resulted in a slight increase in the volume of blood to be drawn for some age groups compared to August 2021–August 2023. The Program verified safe blood draw limits for each age group using the World Health Organization’s safe blood draw limits.

Volume of blood to be drawn based on SP age
Age in years	1	2	3–4	5	6–11	12–17	18+
2025–2026	9 ml	17 ml	17 ml	43 ml	43 ml	79 ml	79 ml
2021–2023	10 ml	20 ml	20 ml	20 ml	45 ml	112 ml	112 ml

Laboratory Assessment Changes for 2025-2026 

Although a few laboratory tests are new or have been removed in 2025–2026, most remain but have been modified. Predominantly, modifications are the result of adjustments in eligibility age as described below. Furthermore, for tests that include a subsample of the entire population, the percentage to be included has increased from one-third in August 2021–August 2023 to one-half in 2025–2026.

The following laboratory tests have not been modified for 2025–2026:

Serum Laboratory Test	Age
CBC	1+
Vitamins D and Vitamin D epimers	1+
Hemoglobin variants (S, C, D, E, F, U)	12+
Fasting Plasma Glucose (all AM participants)	12+
Insulin (Only AM participants)	12+
Hemoglobin A1c (formerly Glycohemoglobin)	12+
High Sensitive C-reactive protein (hsCRP)	1+
Enterovirus D68 Serology	1-11
Total Triiodothyronine	5+
Cadmium	1+
Lead	1+
Manganese	1+
Mercury	1+
Selenium	1+
Urine Laboratory Test	Age
Urine Albumin	3+
Urine Creatinine	3+
Pristine Urine Sample for Storage	3+

The following laboratory tests have been removed for 2025–2026:

Serum Laboratory Test

RBC Folate Forms

Vitamins A, C

Trans Fatty Acids

Creatine Phosphokinase (CPK)

Serum Total Iron Binding Capacity (TIBC)

Serum HPV Antibody

CMV Antibodies (IgG and IgM)

Free Triiodothyronine

Thyroglobulin

RBC Acetylcholinesterase (AChE) Enzyme/Activity

COVID-19 Serology (SARS-CoV-2 antibody)

Herpes Simplex Virus Type 1 (HSV-1)

Herpes Simplex Virus Type 2 (HSV-2)

Human Immunodeficiency Virus (HIV)

Urine Laboratory Test

Chlamydia

Trichomonas

Mycoplasma Genitalium

Urine for Aromatic Diamines (formerly Diisocyanates Metabolites and Urinary Amines)

The following laboratory tests will be new for 2025–2026:

Serum Laboratory Test	Age
B Vitamins (B1 & B2)	5+
B Vitamins 6 and 12	5+
MMA	5+
Free Fatty Acids (Fasting)	12+ fasting
Choline and Metabolites	12+ fasting
Fructose	12+ fasting
Cystatin C	12+
Aldosterone	2+
Angiotensin I (Ang I)	3+
Angiotensin II (Ang II),	3+
Angiotensin 1-9 (Ang 1-9)	3+
Angiotensin 1-7 (Ang 1-7)	3+
HBV DNA	5+
Thyroid Stimulating Hormone Receptor Antibodies	2+
Allergy testing Profile Including Total IgE	1+
To include: Alternaria alternata Ambrosia artemisilfolia (ragweed short/common) Aspergillus fumigatus Birch Cladosporium herbarum Dog and cat dander Dust mite (Dermatophagoides arina, Dermatophagoides pteronyssinus) German cockroach (Blatella germanica) Penicillium Mouse urine proteins Rye and Bermuda grasses Oak, Birch, Russian thistle Cow’s milk Egg, Peanut, Shrimp Alpha-gal Total IgE Wheat, Soy, Sesame, Almond, Cashew, Walnut, Fish (cod)
Urine Laboratory Test	Age
Dietary Polyphenols	3–4 & 50% of 5+
To include: 3,5‐Dihydroxybenzoic acid, Gallic acid, 4‐O‐Methylgallic acid, Caffeic acid, m‐Coumaric acid, p‐Coumaric acid, Ferulic acid, 3,5‐Dihydroxyphenylpropionic acid, Hippuric acid, Phloretin, Catechin, Epicatechin, Epigallocatechin, Hesperetin, Naringenin, Isorhamnetin, Kaempferol, Quercetin, Daidzein, O‐Desmethylangolensin, Equol, Genistein, Enterodiol, Enterolactone, Resveratrol
Prior Pest NEON and UPHOPM	3–4 & 50% of 5+
Other Biospecimens	Age
HPV, Female swab	14-64
HPV, Male swab	14-64
HPV, oral rinse	14-64
Environmental Sample	Age
Fluoride, water	0-17

The following laboratory tests will be modified for 2025–2026. The specific modification is detailed.

Serum Laboratory Test	Age	Modification
Serum Folate	15-44 females	Modified in age eligibility
RBC Folate
Ferritin	all 1–4 and females 12–49
Soluble Transferrin Receptor
Alpha-1-acid-glycoprotein (AGP)
Transferrin
Butyrylcholinesterase Activity & Concentration	5+
RBC Fatty Acids
Total Cholesterol
HDL-Cholesterol
Triglycerides
Hepatitis A Virus (HAV) Antibody (HAV Ab)
HBV Core Antibody (Anti-HBc)
HBV Surface Antigen (HBsAg)
Hepatitis C Virus (HCV) Antibody (HCV Ab)
HCV RNA Quantified (HCV RNA)
HCV Genotype
Hepatitis D Virus (HDV) Antigen (HDAg)
HDV Antibody (Anti-HDV)
Hepatitis E Virus (HEV) IgG Antibodies
HEV IgM Antibodies
Hepatitis B Virus (HBV) Surface Antibody (Anti-HBs)	18+
Testosterone	2+
Estradiol
Sex Hormone Binding Globulin (SHBG)
17α-Hydroxyprogesterone
Androstenedione
Dehydroepiandrosterone Sulfate (DHEAS)
Estrone
Estrone Sulfate
Progesterone
Follicle Stimulating Hormone (FSH)
Luteinizing Hormone (LH)
Cotinine and Metabolites
Anti-Mullerian Hormone (Only Female)	2+	Modified in age and sex eligibility
Perfluoroalkyl and Polyfluoroalkyl Substances (Serum)	50% of 12+	Modified subsample percentage
Polybrominated Diphenyl Ethers (Serum)
Polychlorinated Biphenyls (Serum)
Polychlorinated Dibenzo-p-dioxins and Dibenzofurans
Total Thyroxine (TT4)	2+	Modified in age eligibility and subsampling removed
Total Triiodothyronine (TT3)
Thyroid Peroxidase Antibodies
Thyroglobulin Antibodies
Thyroid Stimulating Hormone
Adducts of Hemoglobin: RBC Acrylonitrile and Ethylene Oxide	5+
Terpenes	50% of 5+	Modified age and subsample percentage
VOC Blood	12+	Modified with subsampling removed

Urine Laboratory Test	Age	Modification
Urine Pregnancy	18-59	Modified in age eligibility
Antimony	3-4 & 50% of 5+	Modified in age eligibility and subsample percentage
Arsenic
Arsenic Speciated
Barium
Cadmium
Cesium
Cobalt
Chromium
Lead
Manganese
Mercury and Speciated Mercury
Molybdenum
Nickel
Strontium
Thallium
Tin
Tungsten
Uranium
Iodine
Flame Retardant Metabolites
Insect Repellents: DEET Metabolites
Neonicotinoid Insecticide Biomarkers
Organophosphate Insecticides: Diakyl Phosphate Metabolites
Perchlorate, Nitrate, Thiocyanate
Phthalates and Personal Care and Consumer Product Chemicals and Metabolites
Polycyclic Aromatic Hydrocarbons (PAHs)
Pyrethroid Pesticides, Herbicides, and Organophosphate Insecticides Metabolites
Tobacco Biomarkers (urine cotinine, TSNA)
VOC, urine

See Attachment 8 for the 2025-2026 and earlier Laboratory Assessment tables.

3. Use of Improved Information Technology and Burden Reduction

NHANES uses survey information technology architecture (SITA) that supports fully automated and integrated information technology. SITA provides increased capabilities that allow processing of complex data with significantly less editing than in previous NHANES surveys.

SITA provides NHANES with access to all data that are collected, much of which is available in real time. The nature of the survey requires that data be accessible at multiple sites including contractor facilities, MECs, laboratories, and NCHS headquarters. SITA supports (1) survey planning and design; (2) data collection; (3) data receipt, control, and quality assurance; (4) reporting of survey results to survey participants; (5) data review, editing, and analysis; (6) generation and documentation of public use data products; (7) tracking of survey respondents; and (8) generation of status reports on all aspects of the survey. 

4. Efforts to Identify Duplication and Use of Similar Information

NHANES is a unique source of health information on the U.S. population. Each year, health interview and examination data are obtained. No other studies collect the detailed health, dietary, laboratory, and examination data that NHANES does. Duplication of effort is avoided through contacts and discussions with numerous agencies during the content development and planning stage of NHANES. The agencies that are consulted for NHANES 2025-2026 are listed in Attachment 9 of this clearance request.  

5. Impact on Small Businesses or Other Small Entities

Only individuals will be asked to participate. No small businesses will be involved in this data collection. 

6. Consequences of Collecting the Information Less Frequently

The continuous nature of the NHANES is necessary for several reasons. First, many of the data items collected in the NHANES are used for tracking of health events and circumstances, including tracking of the National Objectives for Health Promotion and Disease Prevention. Second, the continuous design makes it possible to aggregate data over longer periods of time to include enough cases to study rare events and small populations. Third, nutrition monitoring legislation explicitly calls for continuous coverage to monitor nutrition changes as they occur (see Attachment 1). Fourth, a continuous survey is more cost effective because it makes possible a stable field staff, which increases the quality of the data and avoids startup and shutdown costs. Reducing the frequency of data collection would undermine all of these desirable features of the NHANES. 

In March 2020, NHANES, for the first time since continuous data collection began in 1999, was paused because of COVID-19. In August 2021, NHANES resumed data collection with modified procedures to address participant and staff safety. Data collection continued through August 2023 but paused while the Program adapts the survey and modernizes processes for 2025-2026 data collection. Once data collection begins in 2025, the Program plans to resume continuous annual NHANES data collection.

7. Special Circumstances Relating to the Guidelines for 5 CFR 1320.5

This data collection fully complies with regulation 5 CFR 1320.5. 

In accordance with the 2024 Statistical Policy Directive No. 15 and best practices, NHANES participants are offered a single combined race and ethnicity question in which the minimum reporting categories are listed by population-size per the decennial census. According to the directive, reporting categories are not required to be listed in alphabetical order. However, if NHANES is instructed to order the categories alphabetically, the modification will be made upon submission of the revised 2027-2028 NHANES information collection review package in January 2026.

8. Comments in Response to the Federal Register Notice and Efforts to Consult Outside the Agency

1. Federal Register Notice

A 60-day Federal Register Notice was published on May 13, 2024, volume 89, number 93, pp. 41438 (see Attachment 2a). The Program received no public comments (see Attachment 2b) resulting in no responses to comments (see Attachment 2c).

2. Outside Consultation

NHANES is a collaborative undertaking. The Program seeks broad input from the research community, academia, federal agencies, and other interested parties to maximize the utility of the survey data. NHANES consults with its collaborators and interested agencies through meetings, conference calls, or via email. The Program uses a formal proposal solicitation process via the NHANES website prior to future content planning and development.

In March 2022, DHNES began the process of content solicitation for the 2025-2026 NHANES. This process took place in two phases. The first phase requested interested groups to submit a PDF form that requested a high-level description of the content they were interested in adding to the survey – this request was sent via email to known collaborators and was posted on the NHANES website. DHNES received 40 such forms in response to this solicitation. These forms were reviewed in July 2022. For the second phase, DHNES invited 30 of these submissions to send in a full proposal of the content they suggested for inclusion. Proposal guidelines were also provided at this time. Most of these proposals were accepted for the 2025-2026 NHANES. During this period, a request was also sent to collaborators who had content in the August 2021-August 2023 NHANES to determine whether they wanted to continue their collection in 2025-2026.

NCHS staff gave presentations throughout the year at major medical and public health professional meetings and internal meetings organized by other federal agencies. The meetings provided an excellent forum for updating stakeholders on survey activities and data products. 

In the interim since the 60-day notice was issued, NCHS/DHANES decided to drop the COVID-19 section of the Survey Participant (SP) questionnaire from the 2025-2026 data collection.  Since the 60-day notice was issued, CDC adopted a revised definition of long COVID based on recommendations from the National Academy of Sciences, Engineering, and Medicine.  The revised definition changed the timeframe of long COVID from 4 weeks to 3 months.  Given that the COVID-19 module was largely focused on long COVID, or post-COVID conditions, this change would have great impact on the ability to provide useful information on long COVID with a sufficient sample size.  Due to the timeline in which questionnaire changes needs to be made, it is not feasible at this time to change the existing questions to accommodate the revised definition.

9. Explanation of Any Payment or Gift to Respondents

To maximize response rates for the examination, NHANES SPs have received incentives as remuneration for their examination participation since the 1970s. Informed by the previous incentive pilot results in the August 2021–August 2023 cycle, and with consideration for the overall budget, the updated 2025–2026 NHANES examination and interview incentives are shown in Table 3. The table also details the allowances provided to help participants with the out-of-pocket costs for attending the MEC examination, including:

• Transportation Allowance: The SP will receive a prepaid transportation allowance when agreeing to participate in the MEC exam, the amount of which will depend on how far the MEC location is from the SP’s home as shown below. However, in special circumstances in areas where the MEC is at least 50 miles away and the minimum commute time each way is at least 60 minutes, the participant may receive an incentive amount greater than $70, not to exceed $100. The transportation allowance will be given at the time of scheduling the MEC appointment and the amount will be determined based on the number of trips to the MEC (such that household members traveling together would receive one travel allowance for a single trip to the MEC, and not one allowance per SP). Additionally, NHANES may also temporarily increase the transportation incentive to account for any acute increases in gas prices at the local or national level when the response rate may be affected because of the acute increase.

• Child/Elder Care Allowance: If an SP must hire a caregiver to care for children, elderly, or persons with disabilities so that the participant can leave their home to be examined in the MEC, they are allowed to receive $10.00 an hour for up to 6 hours to help with out-of-pocket costs. 

• Non-survey Participant Allowance: Parents or caregivers of SPs under 18 years old who are not SPs themselves are given a $20 allowance for accompanying their minor SP(s) to the MEC exam.

Table 3. NHANES 2025-2026 Incentive Structure

Incentive Type		2025-2026 Amount
SP Interview (in-home)	Sample Person Questionnaire	$25.00
MEC Transportation Allowance	0.0-15.9 miles	$30.00
	16.0-30.9 miles	$45.00
	31.0-59.9 miles	$55.00
	60+ miles	$70.00
MEC Exams	SP 0-11 years old	$40.00
	SP 12-15 years old	$60.00
	SP 16+ years old	$100.00
Other MEC Allowances	Child/Elder Care per hour	$10.00
	Non-Survey Participant (adult assisting a minor SP)	$20.00
Dietary Follow-up Interviews (telephone)	Day 1 Dietary Recall	$30.00
	Day 2 Dietary Recall	$30.00
	Flexible Consumer Behavior Survey (FCBS)	$0.001

¹The number of questions in the FCBS was substantially reduced from 53 questions to 9 questions for the 2025-2026 cycle. Therefore, the prior FCBS incentive of $15 was removed for 2025-2026.

The total incentive amounts are the same as those approved for the August 2021-August 2023 cycle, except for the MEC examination for SP ages 16 and older, Dietary Recall Questionnaire incentives, and the allowance per hour for child/elder care.

• MEC Examination Incentive: In 2022, as part of an incentive pilot study, NHANES received OMB approval to utilize a $125 MEC examination incentive for SPs 16+ from the initial amount of $85 that was implemented in 2021. The restoration was made in efforts to address decreasing response rates. Utilizing the higher MEC incentive resulted in a 7 percent increase in the MEC exam response rate, a narrower range in response rates across PSUs, and reduced variability in response rates across demographic groups for the experiment age group. The proposed $100 MEC exam incentive for SPs age 16 and older in 2025-2026 is based on success with increased response utilizing a $125 incentive for 2022 and 2023, but because of budget limitations we are not able to provide the additional $25 as we would like. Because evidence supports that an increase above $85 increased response rates, the program proposes this higher amount now and may consider the $125 level in future data collection cycles, should budget allow.

• Dietary Recall Incentive: The proposed $30 dietary recall incentive is intended to boost response rates with SPs now that both interviews will continue to be administered by telephone and outside of the MEC.

• Child/Elder Care Allowance: The proposed $10 per hour allowance for child or elder care to attend the MEC examination has been updated to keep in line with current expectations for the cost of care providers.

Attachment 10 contains a history of NHANES examination response rates and a brief history of NHANES incentives. Other efforts are made to maintain and increase response rates on a day-to-day basis (see Section B.3 Methods to Maximize Response Rates and Deal with Nonresponse). 

10. Protection of the Privacy and Confidentiality of Information Provided by Respondents

Data will be kept private to the extent allowed by law.

This submission has been reviewed by the Information Collection Review Office, which determined that the Privacy Act does apply. The NCHS Privacy Act Coordinator and the NCHS Confidentiality Office have also reviewed this package and have determined that the Privacy Act is applicable because the Generic Information Collection Requests (GenICRs) may include the collection of information in identifiable form. The applicable System of Records Notice is 09-20-0167 Health Resources Utilization Statistics. Specific Privacy Act applicability will be addressed in each GenICR. 

Confidentiality will be provided to respondents as assured by Section 308(d) of the Public Health Service Act (42 U.S.C. 242m(d)) as follows:

“No information, if an establishment or person supplying the information or described in it is identifiable, obtained in the course of activities undertaken or supported under section 304, 306, or 307 may be used for any purpose other than the purpose for which it was supplied unless such establishment or person has consented (as determined under regulations of the Secretary) to its use for such other purpose and in the case of information obtained in the course of health statistical or epidemiological activities under section 304 or 306, such information may not be published or released in other form if the particular establishment or person supplying the information or described in it is identifiable unless such establishment or person has consented (as determined under regulations of the Secretary) to its publication or release in other form.” 

In addition, legislation covering confidentiality is provided according to the Confidential Information Protection and Statistical Efficiency Act or CIPSEA (44 U.S.C. 3561-3583) which states:

“(f) Fines and Penalties. -- Whoever, being an officer, employee, or agent of an agency acquiring information for exclusively statistical purposes, having taken and subscribed the oath of office, or having sworn to observe the limitations imposed by this section, comes into possession of such information by reason of his or her being an officer, employee, or agent and, knowing that the disclosure of the specific information is prohibited under the provisions of this subchapter, willfully discloses the information in any manner to a person or agency not entitled to receive it, shall be guilty of a class E felony and imprisoned for not more than 5 years, or fined not more than $250,000, or both.” 

Standards for federal government surveys highlight the importance of the interviewers’ responsibilities under the Privacy Act of 1974 (5 U.S.C. 552a), the Privacy Act Regulations (34 CFR Part 5b), Section 308(d) of the Public Health Service Act (42 U.S.C. 242m(d)), the Confidential Information Protection and Statistical Efficiency Act or CIPSEA (44 U.S.C. 3561-3583), Health Insurance Portability and Accountability Act of 1996, and other regulations.

NCHS also makes the following Confidentiality Pledge: 

Assurance of Confidentiality (shown on all survey forms)–

We take your privacy very seriously. All information that relates to or describes identifiable characteristics of individuals, a practice, or an establishment will be used only for statistical purposes. NCHS staff, contractors, and agents will not disclose or release responses in identifiable form without the consent of the individual or establishment in accordance with Section 308(d) of the Public Health Service Act (42 U.S.C. 242m(d)) and the Confidential Information Protection and Statistical Efficiency Act or CIPSEA (44 U.S.C. 3561-3583). In accordance with CIPSEA, every NCHS employee, contractor, and agent has taken an oath and is subject to a jail term of up to 5 years, a fine of up to $250,000, or both if he or she willfully discloses ANY identifiable information about you. In addition to the above cited laws, NCHS complies with the Federal Cybersecurity Enhancement Act of 2018 (6 U.S.C. § 663) which protects Federal information systems from cybersecurity risks by screening their networks.

All study data will be collected under the pledge of confidentiality. Consequently, all information collected in Developmental Studies to Improve the National Health and Nutrition Examination Survey and Related Programs will be kept confidential, with an exception for suspected child abuse. When indicated, studies will collect, on a confidential basis, data needed to recontact respondents for additional information and for participation in potential follow-back surveys, and possibly to match respondents to administrative records. The ability to track respondents and match to other records greatly expands the usefulness of these data at very low cost.

Only those NCHS employees, contract staff, and full collaborators who must use the personal information for a specific purpose can access and use such data resulted from the studies. Everyone else who uses the data can do so only after all identifiable information is removed.

NCHS protects confidential information collected in its surveys. The collection of identifiable information requires strong measures to ensure that private information is not disclosed accidentally or deliberately in a breach of confidentiality. All NCHS employees, and all contract staff, receive appropriate confidentiality training and sign a “Nondisclosure Statement.” Staff members of collaborating agencies are also required to sign this statement, and outside agencies are required to enter into a more formal agreement with NCHS. All contractor and NCHS project staff follow strict procedures to collect, monitor, and analyze these data. This procedure prevents information from being removed from the area for purposes other than official NCHS survey data collection. The transmission and storage of confidential data are protected through procedures such as encryption and carefully restricted access. Only those NCHS employees and our full collaborators who must use the personal information for a specific purpose may have access to and use such data.

Prior to release of any data collected under this clearance, the NCHS Disclosure Review Board reviews the information to ensure that disclosure risk is at a minimum. Tabulated data are reviewed to ensure that no disclosure risk exists. 

Overview of the Data Collection Process 

For 2025-2026, a contractor carries out the NHANES data collection. The contractor’s responsibilities include the following activities: 

• makes advance arrangements for each location in sample; 

• sets up and maintains field activities and examination centers; 

• translates all questionnaires as required;

• hires and trains field staff including conducting mock interviews and examinations to ensure adequate hands-on experience prior to working in the field; 

• creates procedure manuals and training programs; 

• conducts an integration test using simulation participants prior to fielding full NHANES 2025-26 data collection; 

• conducts all interviews in the households and by telephone;

• performs all interview and examination procedures in the examination centers;

• tracks performance in the field through monitoring of response rates, review of sample yields, monitoring field staff performance, and checking for data outliers;

• designs and carries out quality control procedures, including MEC equipment calibration and dry run exams in each PSU;

• arranges for gold standard examinations conducted by subject matter experts as part of the quality control process for specific exams; and 

• transmits interview, examination, and laboratory data to NCHS.

Further details on the data collection procedures are included in Supporting Statement Section B.2. Procedures for the Collection of Information and in the referenced attachments. The following is a summary of the attachments related to the data collection procedures.

Screening Material: 

• Advance Household Letter (Attachment 11a)

Consent Materials (Attachment 11b): 

• Home Interview Study Statement 

• MEC Consent Booklet

• Detailed List of NHANES Blood and Urine Tests

• Child 7- to 11-year-old Examination Assent Flyer

Nonresponse Letters (Attachment 11c): 

• Screening Nonresponse Letter

• Interview Nonresponse Letter

• MEC Nonresponse Letter

Material Handouts for gaining participation and answering questions (Attachment 11d):

• Confidentiality Brochure

• Sample Selection Flyer 

• Welcome to NHANES Brochure

• Overview Brochure

• Environmental Exposures Flyer

MEC Examination Materials (Attachment 11e): 

• MEC Appointment Slip

• MEC Reminder Communications (letter, text, and email)

• Lab Blood Flyer

• Community Service Letter

• School Excuse Letter

MEC Examination Results (Attachment 11f): 

• Final Report of Findings Sample

• Early Report of Findings Documentation

Dietary Interview Materials (Attachment 11g) 

• Dietary Interview Appointment Slip

• Dietary Interview Day 1 Thank You Letter

Items of Information to be Collected 

NHANES consists of the examination (conducted in the MEC), laboratory analytes, the home interview (conducted at the DU prior to the examination) and two telephone dietary interviews (conducted either before or after the MEC exam). See below for additional information about the information collected in the examination, laboratory assessments, and interviews. 

NHANES Examination 

• Anthropometry Body Measurements

• Blood Pressure and Pulse Measurements

• Oral Health

• Respiratory Health

• Audiometry

• Visual Acuity

• Ophthalmology

• Bone Density Measurement by Dual Energy X-Ray Absorptiometry

NHANES Laboratory Assessments via serum, urine, swabs, oral rinse and household water collection include:

• Renal and hepatic function 

• Environmental chemical exposures 

• Infectious disease and sexually transmitted infection assessments 

• Nutritional including anemia status 

• Biologic specimen banking 

• Human papillomavirus infection

• Lipid profile

• Inflammatory disease

• Thyroid health status

• Reproductive hormone panel

• Blood pressure panel

• Allergy panel

• Diabetes panel 

• Biochemical panel 

• Inflammatory disease profile 

 NHANES Interviews 

• Demographic information 

• General health information 

• Medical conditions

• Food security and nutrition program participation 

• Dietary recall 

• Dietary supplement use

• Prescription drug use 

• Mental health

• Alcohol use

• Cigarette and tobacco use 

• Reproductive health and history 

• Sexual behavior

• Health insurance information

• Income information

Information in Identifiable Form 

Information in identifiable form is collected for linkage with other federal sources of data, to allow future recontact of participants and to notify participants of health test results. The identifiable information includes: 

• Name 

• Date of birth 

• Social Security number (SSN) 

• Medicare Beneficiary Identifier (MBI)

• Proxy’s First Name and relationship to child 

• Sex 

• Mailing address 

• Phone numbers 

• Email address 

• Medical information and notes 

• Employment status 

• Contact information for two people close to the household questionnaire respondent 

Please see Section A.11 Justifications for Sensitive Questions for more details.

The NHANES continues to collect personally identifying information, on a confidential basis, needed to recontact respondents and to match respondents to administrative records such as the National Death Index (OMB. No. 0920-0215, Exp. Date 05/31/2026). The ability to track respondents and match to other records greatly expands the usefulness of the data at very low cost. Only those NCHS employees, specially designated agents, and our full collaborators, who must use the personal information for a specific purpose, can use such data.

NHANES mails an Advance Household Letter to each DU briefly describing the survey, providing contact information for NHANES, and explaining that a Field Interviewer will be visiting the DU (Attachment 11a). The informed consent documents (Attachment 11b) for the interview, the examination, and the stored specimens each repeat the confidentiality assurance. 

It is the responsibility of all employees of NCHS, including NCHS contract staff, to protect and preserve all NHANES data (this includes all oral or recorded information in any form or medium) from unauthorized persons and uses. All NCHS employees and all contract staff have received appropriate training and made a commitment to ensure confidentiality and have signed a “Nondisclosure Affidavit.” Staff of collaborating agencies are also required to sign this statement, and agencies are required to enter into a formal Designated Agent Agreement with NCHS before access to non-public data is permitted. It is understood that protection of the confidentiality of records is a vital and essential element of the operation of NCHS and that federal law demands that NCHS provide full protection at all times of the confidential data in its custody. Only authorized personnel are allowed access to confidential records and only when their work requires it. When confidential materials are moved between locations, records are maintained to ensure that there is no loss in transit, and when confidential information is not in use, it is stored in secure conditions. The transmission and storage of confidential data are protected through procedures such as encryption and carefully restricted access.

NCHS policy requires physical protection of records in the field and has delineated these requirements for the data collection contractor. The contractor also has its own policy and procedures regarding assurance of confidentiality and a pledge that all employees involved in NHANES must sign. The contractor provides all safeguards mandated by the Privacy Act and confidentiality legislation to protect the confidentiality of the data. The contractor’s data security procedures comply fully with security requirements delineated by the Information Resources Management Office of CDC. 

It is NCHS policy to make NHANES data available via public use data files to the scientific community. However, NHANES does not release confidential data to the public. For example, all personal information that could be potentially identifiable (including participant name, address, survey location number, sample person number) are removed from the public release files. The NCHS Disclosure Review Board reviews all files to ensure that directly or indirectly identifiable data are not included in public releases. 

11. Ethics Review Board (ERB) and Justification for Sensitive Questions

NHANES is subject to review by the NCHS Research ERB. On July 11, 2024, the ERB approved data collection and determined that NHANES 2025-2026 is a public health surveillance activity under the 2018 requirements of the Common Rule (45 CFR 46.102(I)(2)) (see Attachment 1).

Descriptions of self-reported and objective data of a sensitive nature are as follows. 

a. Social Security Number 

SSN is requested in the household interview as a key item. The information is used to link administrative and vital records, such as the National Death Index, to the survey information. Because this information is only used for data linkage purposes, in 2025-2026, SSN will only be requested of participants who provided consent for data linkage.

Permission to data linkage is obtained from respondents as follows: 

In the Household: 

“To better understand health conditions, we ask participants about linking their survey data with other health records. I want to play a short video for you that explains this process.

INTERVIEWER INSTRUCTION:

PLAY DATA LINKAGE CONSENT VIDEO. WHEN VIDEO ENDS, CONTINUE BELOW.

We can do additional health studies by linking your interview and exam data to vital statistics, health, nutrition, and other related records. May we try to link your survey records with other records?”

If the participant consented to the linkage, a follow-up question will be asked to request the SSN:

“Thank you. In addition to other information you have provided, your social security number will help us improve the data linkage. Providing this information is voluntary. There will be no effect on your benefits if you do not provide it. What is your Social Security Number?

In the MEC: 

If an SP has consented to the data linkage during the SP interview but did not provide the SSN, the SP will be asked about the SSN in the MEC using the following question:

“During the home interview, you agreed to have your survey data linked with other health records to help researchers learn more about health conditions. Your social security number will help us improve the data linkage. Providing this information is voluntary. In addition to other information you have provided, your number will be kept private. There will be no effect on your benefits if you do not provide it. What is your Social Security Number?”

If the SP still hesitates, an attempt will be made to collect the last 4 digits of the SSN:

“I understand your concern. Would you provide us with the last four digits of your Social Security Number? This information will allow researchers to match NHANES survey data with health-related records to study important things like changes in health status, eating patterns and health care costs. May I have the last four digits of your Social Security Number?”

b. CMS Medicare Beneficiary Identifier 

Participants covered by Medicare and who consented to the data linkage will be asked to provide the CMS MBI. This will be used to link to Medicare records for further health studies and to link with other records for possible recontact of NHANES participants.

The question is asked as follows: 

“Earlier you consented to linking your survey data with other records using information from the survey. Another way that we link to people’s records is using their Medicare number. Please look at your Medicare card and tell me the Medicare Number on the card.

This number is needed to allow Medicare records of the Centers for Medicare & Medicaid Services to be easily and accurately located and identified for statistical purposes. Providing the Medicare Number is voluntary and collected under the authority of Section 306 of the Public Health Service Act. Whether the number is given or not, there will be no effect on your benefits. This number will be held confidential. [The Public Health Service Act is Title 42, United States Code, Section 242K.]”

c. Residency Status 

Information about country of birth and length of residency in the United States is requested and may be sensitive for recent immigrants. This information is important in analyzing health and nutrition data because acculturation may be related to use of the health care system, diet, and health practices. Additionally, recent immigrants may not have access to health, nutrition, and income assistance programs that affect access to health care and health and nutrition status. Interviewers will be trained to reassure participants that the information is confidential and will be used for statistical reporting only. 

d. Other Content 

Some of the NHANES topics include potentially sensitive questions or examinations. In the informed consent procedure, all SPs are advised of the voluntary nature of their participation in the survey or in any of its content. Again, during the physical examination, each SP is reminded that they can refuse to answer questions or to undergo any parts of the examination they find objectionable. 

The NCHS ERB reviews all questions and procedures (see Attachment 12). The potential sensitivity of questions and procedures is an evaluation criterion in determining content of the survey. The multipurpose nature of NHANES makes it necessary to exclude topics so sensitive that they may interfere with participation.

Questions and procedures thought to be sensitive are listed below. Most of these are questions commonly asked in health care settings. NHANES asks sensitive questions in private settings within the MEC for adolescents and within the home interview for adults.

1. Sexual behavior and sexually transmitted diseases: Information on sexually transmitted diseases—hepatitis B and C, and HPV—is obtained through questionnaires, exams, and lab tests. It is essential to clarify risk factors and identify at-risk population subgroups associated with infection to plan and evaluate prevention programs. This requires self-reported information on sexual behavior combined with objective data on infection.

Questions on sexual activity are asked of males and females 14 to 64 years of age. These questions are administered using ACASI methods in a private room in the MEC. The results of tests for hepatitis B and C are provided to examinees through early reporting (if testing indicates an infection) and along other reportable results in the final report of findings. HPV results are not reported to SPs as the method was developed for health surveillance purposes and should not be used to make clinical decisions. If an SP is concerned specifically about the risk of cervical HPV infection, they may want to request their results. In such cases, the Chief Medical Officer will communicate directly with the lab and provide those results to the SP telephonically. The participant will be informed that the results should not be used to make clinical decisions. If after receiving results the participant specifically requests a written report, the Chief Medical Officer will use a specific letter that details the limits to the test and reiterates that it should not be used to make clinical decisions. 

2. Drugs, alcohol, and tobacco: Drug, alcohol, and tobacco use are risk factors for many of the health conditions studied in NHANES. Participants 12 years of age and older are asked about alcohol consumption and tobacco use. Illicit drug use questions are asked of participants 12 to 64 years of age. The illicit drug use questions are administered using ACASI methods in a private room in the MEC. The alcohol and tobacco questions are administered for participants 12-17 years of age using ACASI in a private room in the MEC and in the home interview for participants 18 years of age and older.

3. Reproductive health and menstruation: Questions on reproductive health history asked of females 12 years of age and older may be considered sensitive by some respondents. The interviews are conducted using ACASI methods for participants 12-17 years of age in a private room in the MEC and for participants 18 years of age and older in the home interview.

4. Age of first menstruation is obtained for females 12 years of age and older. This question is also asked of parents/guardians of girls 8 to 11 years of age during the home interview. If girls 8 to 11 started their menstrual period, the parent/guardian is asked whether the adolescent is currently pregnant during the MEC visit. This information is necessary for interpretation of biochemical and hematological assessments.

5. Mental health: Adolescents 12-17 years of age are asked a short depression screening module called the Patient Health Questionnaire or the “PHQ-8.” The questions are taken from the depression module of the PRIME-MD, a self-administered questionnaire that was first used in clinical settings. The interviews are conducted in a private room in the MEC using ACASI methods. Adults 18 years of age and older are asked these questions using ACASI methods in the household visit.

6. Male and female urologic health: Conditions such as urinary incontinence and gynecologic infections affect millions of Americans. The information collected in NHANES is critical to understanding the magnitude of these problems and their impact on health and quality of life. The interviews are conducted in the home interview for participants 18 years of age and older using ACASI method. 

7. Future content: As discussed in the Responding to Emerging Public Health Issues, New Technology and Future Survey Options portion of Section A.2., during NHANES, new content may be pilot-tested or added, as new diagnostic procedures become available or as new conditions emerge. This content will be handled in similar fashion to that discussed above in the introduction to this section (Section A.11d Other Content). Information will be explicitly discussed in the informed consent document if the content is considered sensitive, and appropriate privacy and confidentiality safeguards included. 

12. Estimates of Annualized Burden Hours and Costs

a. Time Estimates

This submission requests OMB approval for 3 years. Table 4 shows the estimated annual burden for each survey component within this submission. The total estimated burden for 1 year of NHANES remains at 26,040 hours, including screening, household interview, examination, and follow-up interviews (lines 1-5 of Table 4). The remaining 10,500 hours of burden are for developmental projects, pilots, work in advance of special studies, etc. The total requested burden for all projects combined is 36,540 hours.

The annual estimated burden for the various components of NHANES is outlined below: 

• The NHANES screener (Attachment 6a) is budgeted for 7 minutes—the maximum number of respondents would be 6,398 and the maximum burden 747 hours. The estimate for screening was decreased from that of NHANES August 2021-August 2023 to account for the reduction of questions within the instrument.

• The NHANES household interview (Attachment 6b-6f) is budgeted for 1 hour—the maximum number or respondents would be 5,882 and the maximum burden 5,882 hours. This estimate is the same as NHANES August 2021-August 2023. Although there is a reduction in the total number of questions being asked in the interview, collection of water in the home was added. This estimate also includes time for SPs to schedule their MEC examination and first dietary telephone interview.

• The NHANES MEC Interview and Examination (Attachment 6g-6h) is budgeted for 2 hours—the maximum number of participants would be 5,000 and the maximum burden 10,000 hours. The reduction from 2.5-hour exams in NHANES August 2021-August 2023 to 2 hours exams is largely the result of the elimination of extra cleaning time (implemented during the COVID pandemic) in the MEC between participants as the planned flow of participant activities reduces wait times.

• The Day 1 telephone Dietary Recall, Dietary Supplements, and Flexible Consumer Behavior Survey Phone Follow-Up (Attachments 6j and 6m) is budgeted for 1 hour—the maximum number of respondents would be 5,882 and the maximum burden 5,882 hours. The Day 2 telephone Dietary Recall and Dietary Supplements (Attachment 6k) is budgeted for .6 hours—the maximum number of respondents would be 5,882 and the maximum burden 3,529 hours.

Adult respondents who participate in all the above aspects of NHANES can expect a total estimated burden of up to 4.7 hours. This is a reduction from the August 2021-August 2023 estimate of 5.3 hours. 

Up to 3,500 additional persons (including non-NHANES respondents) might participate in developmental projects (such as pilot tests or methodological studies) or testing ahead of Special Studies, if budgeted. The average burden for these respondents is 3 hours (Attachment 13). The estimated total burden for 1 year for special studies is 10,500 hours.

Table 4. Annualized Burden Hours 

Type of Respondent	Form Name	Number of Respondents	Number of Responses per Respondent	Average Burden per Response (in hours)	Total Burden (in hours)
Individuals in households	Screener	6,398	1	0.1	747
Individuals in households	Home Interview	5,882	1	1	5,882
Individuals in households	MEC Interview & Examination	5,000	1	2	10,000
Individuals in households	Day 1 Telephone Dietary Recall, Dietary Supplements, & and Flexible Consumer Behavior Survey Phone Follow-Up	5,882	1	1	5,882
Individuals in households	Day 2 Telephone Dietary Recall & Dietary Supplements	5,882	1	.6	3,529
Individuals in households	Developmental Projects & Special Studies	3,500	1	3	10,500
Total					36,540

b. Cost to Respondents 

The mean hourly wage rate of $29.76 per person is based on income from wages and salary from the Bureau of Labor Statistics: http://www.bls.gov/oes/current/oes_nat.htm#00-0000 (last updated 04/25/23). This wage rate for all persons was used because respondents do not fall into a single economic or occupational category. (Note: There are no out-of-pocket costs to survey participants. Participants are given an incentive as remuneration for their time and to help with out-of-pocket expenses such as child/elder care and transportation.) 

Table 5. Cost to Respondents 

Type of Respondent	Form Name	Total Burden (in hours)	Hourly Wage Rate	Total Respondent Costs
Individuals in households	Screener	747	$29.76	$22,231
Individuals in households	Household Interview	5,882	$29.76	$175,049
Individuals in households	MEC Interview & Examination	10,000	$29.76	$297,600
Individuals in households	Day 1 Telephone Dietary Recall, Dietary Supplements, & and Flexible Consumer Behavior Survey Phone Follow-Up	5,882	$29.76	$175,049
Individuals in households	Day 2 Telephone Dietary Recall & Dietary Supplements	3,529	$29.76	$105,023
Individuals in households	Developmental Projects & Special Studies	10,500	$29.76	$312,480
Total				$1,087,432

13. Estimate of Other Total Annual Cost Burden to Respondents and Record Keepers

There are no additional costs. 

14. Annualized Cost to the Federal Government

This project is a multiyear, continuous survey, with survey planning, data processing and analysis, and data collection occurring simultaneously. These figures are broad estimates based on past NHANES data collection budget estimates. Staff costs were primarily based on Division of Health and Nutrition Examination Surveys personnel costs, which were obtained from the NCHS Office of Financial Resources. A proportion of these costs are paid by funds transferred to the CDC budget from collaborating agencies. It is estimated that about 60 percent of survey costs will be covered through this support from agencies outside of NCHS. 

Table 6. Estimated Survey Cost per Year 

Category	Annualized Cost
Equipment, exam centers, data collection and processing, contracts, labs/readings	$44,000,000
NCHS staff costs for survey planning, data analysis and overhead	$6,000,000
NCHS printing, travel, supplies, etc. for NHANES staff	$200,000
Total	$50,200,000

15. Explanation for Program Changes or Adjustments

The new requested burden for this submission is 36,540 hours, a reduction of 29,090 hours from the prior 65,630 hours. The burden table (see Section 12) shows each level of possible participation (screener, interview, exam, dietary interview, etc.) in NHANES as a separate line item. The overall burden is reduced greatly by the removal of the 24-hour wearable device projects, noted in the prior data collection cycle. The reduction in the burden estimates for the main parts of NHANES (screener through post MEC interviews) is driven by two changes:

• the screener instrument has been streamlined along with sample design that requires screening fewer households, and

• the MEC examination time has been reduced by a revised participant flow through exam components that reduces waiting and cleaning times.

16. Plans for Tabulation and Publication and Project Time Schedule

The following are key activities and projected completion goals for the 2025-2026 NHANES: 

Activity	Project Completion
Planning survey content	December 2023
2025-2026 data collection	February 2025 through December 2026
First public release of data	September 2027
First publication of summary statistics	September 2027

17. Reason(s) Display of OMB Expiration Date is Inappropriate

We have several forms that are pasted into glossy, multipage brochures, which require considerable advance time for printing. To save substantial printing costs, since 1999 OMB has granted an exception from printing the expiration date on these forms for data collection. We request that exemption be continued through the term of this clearance. 

18. Exceptions to Certification for Paperwork Reduction Act Submissions

The certifications are included in this submission.

Appendix A

2025-2026 NHANES Added Questions and Validation/Justification

	Collaborator		Added Questions		Validation or Justification		Section of Interview
	DHNES		A question ascertaining whether someone who is 18 or older is available in the HH (YES/NO) and scripting to ask when a good time would be to return.		This question has been in the survey since 1999.		Screener
	Kellie O'Connell (Cassavale), Office of Nutrition and Food Labeling Center for Food Safety and Applied Nutrition, Food and Drug Administration, [email protected]		Early childhood: Added questions about pre-pregnancy biological mother’s weight and height.		Question has previously been included in NHANES 2019-2020.		SP Questionnaire
	DHNES		Healthcare utilization: Added back the question about the length of time since last health care visit.		Question was used in NHANES 2017-2020.		SP Questionnaire
	DHNES		Immunization: Two new questions have been added to ask about hepatitis B vaccine.		This is a modified version of the hepatitis B immunization question from the 2019-2020 Immunization questionnaire to reflect availability of 2-dose regimen hepatitis B vaccines.		SP Questionnaire
	DHNES		Medical conditions: Added questions about age asthma first diagnosed, taking steroids for asthma, asthma caused or symptoms made worse by the job, subjective cognitive decline, and family history on asthma, diabetes, breast cancer, colon/rectal cancer, heart attack/angina before the age of 50, and stroke before the age of 65.		The questions on asthma and allergy are either taken directly from previous national survey instruments that use the definition of asthma endorsed by the Council of State and Territorial Epidemiologists for surveillance; or have been developed by a team of SMEs from the National Institutes of Health (i.e., NIEHS, NIAID, NHLBI) and CDC. Many questions previously asked in NHANES 2017-2018.		SP Questionnaire
	Ruth Jiles, National Center HIV, VH, STD, and TB Prevention Division of Viral Hepatitis, [email protected]		Hepatitis: Added questions about history of Hepatitis C and prescribed medication for Hepatitis B and Hepatitis C.		Return to 2019-2020 version of the Hepatitis Questionnaire.		SP Questionnaire
	Kai Bullard, National Center for Chronic Disease Prevention and Health Prom. Division of Diabetes Translation, [email protected]		Diabetes: Added questions about specifying type of diabetes, checking A1C, and diabetes affecting SP’s eyesight.		Some proposed items contain improved wording aligned with validated, state-based BRFSS or NHIS survey questions; some items were previously in the 2017-2018 or 2019-2020 NHANES cycles. New items to NHANES have been previously validated and used in other population-based surveys and will be critical to monitor risk factors for and burden of diabetes- related complications.		SP Questionnaire
	Kristy Nicks, National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), [email protected]		Osteoporosis: Added new section that asks about broken or fractured hips, wrists, or spine, osteoporosis, medication prescribed for osteoporosis, taking prednisone or cortisone pills daily, and whether the SP’s biological mother and father ever fractured their hips before or after the age of 50.		The osteoporosis questionnaire proposed is the same as the questionnaire used in NHANES 2017-2020 (OSTEOPOROSIS questions, included in supplemental information).		SP Questionnaire
	Michael Wolz, National Heart, Lung and Blood Institute, [email protected]		Respiratory health and allergy: Added new section that asks about SP’s experience with wheezing, coughing, shortness of breath, seasonal or year-round allergy symptoms, eczema or atopic dermatitis, and food allergies.		Subset of the questions have been slightly modified from previous cycle of NHANES or combined questions from other studies.		SP Questionnaire
	Jinan Saaddine and John Omura, Vision Health Initiative, Division of Diabetes Translation National Center for Chronic Disease Prevention and Health Promotion, [email protected], [email protected]		Vision: Added new section that asks about SP’s ability to see light, blindness, difficulty doing certain activities that involve eyesight, last eye exam, glaucoma, age-related macular degeneration, cataract surgery, and diabetic retinopathy.		Vision questionnaire builds upon the previous Vision Section Questionnaire of the NHANES 2007-2008 and the Diabetes Questionnaire.		SP Questionnaire
	Howard Hoffman, National Institute on Deafness and Other Communication Disorders (NIDCD), [email protected]		Audiometry: Added questions about usage of hearing aid, hearing without hearing aid, ear infections or temporary hearing loss, bothersome ringing or buzzing, dizziness and balance problems, migraines or severe headaches, significant head injury or concussions, bothered by everyday sounds or noises, use of earphones to listen to music, receiving Special Education or Early Intervention Services for developmental or disability problems, diagnosed child developmental disorders related to hearing issues, and exposure to loud and very loud noise, both during and outside of work.		All the questions have been previously used in NHANES or NHIS – many of them multiple times. Most recently NHANES 2017-2020.		SP Questionnaire
	Gina Thornton-Evans, National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP), Division of Oral Health, [email protected]		Oral health: Added questions about SP’s last visit to the dentist, ability to access dental care, personal oral hygiene practice, use of toothpaste, receiving of dental sealants, preventive conversations with a dental hygienist, self- perceived periodontal disease, preventive examinations for oral cancer, and personal use of tap water at home.		Twenty-four of the twenty-seven questions proposed for the NHANES 2024 OHQ component were used in NHANES cycles 2019-2020, 2021-2022, and some questions were also present in earlier NHANES cycles; three of the proposed questions are new. Validation and cognitive studies have been conducted for the OHQ questions related to dental care utilization and access to care, direct conversation with dental professionals, dental self-care methods, and self-reported periodontal disease, and oral health related quality of life (OHRQL). The OHRQL questions, first included in NHANES 2003-2004, are a short instrument adapted from the Oral Health Impact Profile – 14 items (OHIP-14) and have been previously validated.		SP Questionnaire
	Michael Wolz, National Heart, Lung and Blood Institute, [email protected]		Sleep disorders: Questions about snoring while sleeping, snorting or gasping while sleeping, diagnosis of trouble sleeping by a doctor, and diagnosed sleep apnea.		Questions were previously included in NHANES 2017-2020 and prior cycles.		SP Questionnaire
Richard Lucas, USDA-Food and Nutrition Service, [email protected]; AFNG-EAR- [email protected]		Diet behavior and nutrition: Added one question about source of water for preparing infant formula for SPs 23 months of age or younger. Added one question on the frequency of introducing new food to infant for SPs 11 months of age or younger. Added questions on the consumption frequency for specific foods in the last 7 days and questions on childcare for SPs 4 years of age or younger. Added questions about My Plate program. Added one question on current milk consumption pattern. Added one question on the type of cereal SP < 2 years ate. Added a question on whether the spinach was a commercially prepared baby food or made from ingredients at a home. Added a question on the number of hours SP received care from someone other than the parent or guardian.		Questions were from previous NHANES cycles, including 2017- 2020.		SP Questionnaire
DHNES		COVID-19: Added one question on time since last having/suspected of having COVID-19.		This question compliments the COVID-19 serology and is modified from NHANES August 2021-August 2023.		SP Questionnaire
DHNES		Occupation: Added one question on work schedule.		Question has been asked in previous NHANES cycles from 2005-2010 and then again from 2017-2020.		SP Questionnaire
DHNES		Acculturation: Added questions on the language the SP speaks more often at home, if multiple languages were reported.		Similar to questions used in NHANES August 2021-August 2023.		SP Questionnaire
Jaime Gahche, Office of Dietary Supplements; B- 24 group, [email protected];		Infant formula: Added new section for SPs 1 year of age or younger about infant and toddler formulas used in the last 2 weeks. Includes questions about the number of formulas taken, formula’s name, and the length of time the SP has been fed with the formula. The interviewer will ask to see the container(s) of the formula and record brand name, base, form, added ingredients or descriptions, and manufacturer.		The questionnaire has been successfully implemented in NHANES 2019-2020.		SP Questionnaire
DHNES		Prescription medication: Added questions about the use of prescription medication(s). Interviewer will ask to see the container(s) of the medication(s) that the SP takes. Interviewer records the medication name and asks about the duration of use and the reason for use. Added a question to the use of low-dose aspirin module on whether advised by a doctor to stop taking low-dose aspirins. In addition, the target group for the module is restricted to 45 years and older (previously 40 years and older).		Questions on the use of prescription medications were brought back from the 2019-2020 cycle to provide more details information on the topics.		SP Questionnaire
DHNES		Housing characteristics: Questions Added One question ascertaining how long the SP has lived at the address Main source of tap water Presence of mildew or musty smell in the last 12 months Presence of cockroaches in the last 12 months Presence of small furry animals in the last 12 months Household member avoided bringing new pets to or removed pets due to allergies or asthma concerns		Similar questions in CDC/HUD/EPA Asthma Checklist and the Alberta Health System (AHS).		Household Questionnaire
James Tsai, Office on Smoking and Health (OSH), [email protected]		Tobacco: Added a new question about use of heated tobacco products in the past 5 days. Added a new question about total number of days respondent used any of the tobacco products they endorsed within the past 5 days. Added a new question about the last time the respondent used any of the tobacco products they endorsed. Smoking: Questions Added Whether smoking inside the home is allowed Whether smoking inside household vehicles is allowed		All three proposed questions are valid, reliable, and cognitively tested since they are adopted directly from NHANES or other national surveys, such as the National Adult Tobacco Survey and the National Youth Tobacco Survey. The verbatims are conforming with existing NHANES questions and quality standard.		MEC Interview and Household Questionnaire
Ruth Jiles, National Center HIV, VH, STD, and TB Prevention Division of Viral Hepatitis, [email protected]		Drug use: Added question asking about ways in which marijuana was used in the past 30 days. Added question about time since respondent last used a needle to inject a non-prescribed drug.		Modified from the NHANES August 2021-August 2023 Drug Use questionnaire.		MEC Interview
Lauri Markowitz, National Center for Immunization and Respiratory Diseases (NCIRD), [email protected]		Sexual behavior-female: Added a question on ages first had any kind of sex. Added a question asking for total number of lifetime male oral sex partners. Added 2 questions on ever performed oral sex on a female partner, and (if yes), total number of lifetime female oral sex partners.		Previously collected in NHANES 2019-2020.		MEC Interview
Lauri Markowitz, National Center for Immunization and Respiratory Diseases (NCIRD), [email protected]		Sexual behavior-male: Added a question on ages first had any kind of sex. Added a question asking for total number of lifetime female oral sex partners. Added 2 questions on ever performed oral sex on a male partner, and (if yes), total number of lifetime male oral sex partners.		Previously collected in NHANES 2019-2020.		MEC Interview
Jaime Gahche, Office of Dietary Supplements; B- 24 group, [email protected];		Dietary supplements: Added two new questions to supplements series: one asking whether the supplement was taken in the previous day and (if yes) one asking how much of the supplement had been taken in the previous day. Added two new questions to antacids series: one asking whether the antacid was taken in the previous day and (if yes) one asking how much of the antacid had been taken in the previous day.		The 30 day frequency questionnaire has been asked in NHANES since 1988 and has provided prevalence estimates of use, types of products taken, frequency and amounts taken, and the motivations for taking these products. These questions were used in prior NHANES survey (before Aug 2021-Aug 2023).		Dietary Supplements

1 In preparation for the 2025-26 survey, we sent out an invitation to collaborators to suggest content for the survey. Once content was accepted and plans started to solidify as to methodology and logistics, we met regularly with these collaborators. Additionally, a webinar was held for all collaborators in May of 2024. All members of the NCHS BSC were updated and consulted on 9/14/2023 regarding our plans for the 2025-26 redesign.

2 The public data files for the 2017-March 2020 files were released in May 2021 and are located here: NHANES Questionnaires, Datasets, and Related Documentation. The data were combined on an individual level so that the 2017-March 2020 file included all individuals sampled over this period. The 2019-2020 primary sampling units (PSU) that were visited by March 2020 were treated as a partial probability sample. The first step was defining a sample design for the combined 2017-March 2020 data by reassigning 2019-March 2020 PSUs to the 2015-2018 design from which the 2017-2018 PSUs were drawn. The final design included 48 PSUs (30 from 2017-2018 and 18 from 2019-March 2020) that represented all 14 strata in the 2015-2018 design and was thus nationally representative. The sample weights were then adjusted to account for the uneven distribution of PSUs across the 14 strata.

These methods to combine 2017-2018 and 2019-March 2020 are described fully here (starting on p4): Vital and Health Statistics, Series 2, Number 190.

3 The objective of the feasibility study was to obtain complete blood pressure (BP) and pulse data for children ages 3-7 years, specifically achieving three sets of BP and pulse readings for each participant. However, technical challenges arose with the device used in the study. For approximately 30% of children in this age group, the device generated error messages during measurements, compared to error rates of approximately 1% with similar devices in other settings. These frequent errors significantly impacted data completeness, with only 70% of participants in this age group having complete data (i.e., three sets of BP and pulse readings). In response, the program is researching alternative BP devices to ensure more reliable measurements and reduce error rates in future studies involving children ages 3-7 years.

4 None of these exam components added in the 2025-2026 NHANES cycle went through cognitive testing during the survey planning stage. However, all have been conducted in previous NHANES and some, such as audiometry and oral health exams, were administered in the previous survey over decades. As emphasized in the NHANES proposal guidelines, exam components employ protocols that are well established for population studies, and with validity and reliability covering the targeted age range and diverse population. All components provided information to support their inclusion. For example, the NHANES Oral Health examination has been considered the gold standard to provide national population surveillance data on oral conditions. The oral health examinations from previous NHANES have demonstrated high level of validity and reliability (Dye et al. 2019; Dye et al. 2008; Dye et al. 2007a). The NHANES 2011–2014 quality assessment showed that the inter-reference examiner reliability Kappa scores among examiners were 0.96 to 1.00 for tooth count, 0.93 to 1.00 for caries, 0.74 to 1.00 for untreated caries, and 0.85 to 0.88 for sealants.

36