Information Collection

[NCHS] Collaborating Center For Questionnaire Design and Evaluation Research

IC 259654 under ICR 202504-0920-019 · OMB 0920-0222.

⚠️ Notice: This information collection may be referencing outdated material.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

2026-07-06 - Reinstatement without change of a previously approved collection

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-0222-23EC [NCHS] Collaborating Center For Questionnaire Design and Evaluation Research	Form and Instruction
Form 0920-0222-23EC RANDS 8 Questionnaire [NCHS] Collaborating Center For Questionnaire Design and Evaluation Research	Form and Instruction
0920-0222-23EC RANDS 8 Questionnaire Attachment 1 -RANDS 8 Questionnaire.docx	Form and Instruction
0920-0222-23EC RANDS 8 Questionnaire Attachment 1 -RANDS 8 Questionnaire.docx	Form and Instruction
Attachment 2- Advertisement.docx Attachment 2- Advertisement	IC Document
Attachment 2- Advertisement.docx Attachment 2- Advertisement	IC Document
Attachment 3- Screening Script.docx Attachment 3- Screening Script	IC Document
Attachment 3- Screening Script.docx Attachment 3- Screening Script	IC Document
Attachment 4 - Informed Consent.docx Attachment 4 - Informed Consent	IC Document
Attachment 4 - Informed Consent.docx Attachment 4 - Informed Consent	IC Document
Attachment 5- Thank You Letter.docx Attachment 5- Thank You Letter	IC Document
Attachment 5- Thank You Letter.docx Attachment 5- Thank You Letter	IC Document
Attachment 6-Data Retention Policy.docx Attachment 6-Data Retention Policy	IC Document
Attachment 6-Data Retention Policy.docx Attachment 6-Data Retention Policy	IC Document
Attachment 7 - NCHS Non-Disclosure Affidavit.docx Attachment 7 - NCHS Non-Disclosure Affidavit	IC Document
Attachment 7 - NCHS Non-Disclosure Affidavit.docx Attachment 7 - NCHS Non-Disclosure Affidavit	IC Document
Attachment 8 - NORC CIPESA Protection Plan.docx Attachment 8 - NORC CIPESA Protection Plan	IC Document
Attachment 8 - NORC CIPESA Protection Plan.docx Attachment 8 - NORC CIPESA Protection Plan	IC Document
SSA- RANDS 8.docx SSA- RANDS 8	IC Document
SSA- RANDS 8.docx SSA- RANDS 8	IC Document
SSB- RANDS 8.docx SSB- RANDS 8	IC Document
SSB- RANDS 8.docx SSB- RANDS 8	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

[NCHS] Collaborating Center For Questionnaire Design and Evaluation Research

Agency IC Tracking Number:

0920-0222-23EC

IC Status: Unchanged

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	0920-0222-23EC				Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 16,600

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Previously Approved
Annual Number of Responses for this IC	16,600	16,600
Annual IC Time Burden (Hours)	4,150	4,150
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachment 2- Advertisement		04/12/2023
Attachment 3- Screening Script		04/12/2023
Attachment 4 - Informed Consent		04/12/2023
Attachment 5- Thank You Letter		04/12/2023
Attachment 6-Data Retention Policy		04/12/2023
Attachment 7 - NCHS Non-Disclosure Affidavit		04/12/2023
Attachment 8 - NORC CIPESA Protection Plan		04/12/2023
SSA- RANDS 8		04/12/2023
SSB- RANDS 8		04/12/2023

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

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