[NCHS] CCQDER's Caregiver

[NCHS] Collaborating Center for Questionnaire Design and Evaluation Research

Documents and Forms

Document Name Document Type
[NCHS] CCQDER's Caregiver Form and Instruction
Caregiving Questions Attachment 1-Caregiving Questions.docx Form and Instruction
Caregiving Screening Script Attachment 3- Caregiving Screening Script.docx Form and Instruction
Respondent Data Collection Sheet Attachment 5- Respondent Data Collection Sheet.docx Form and Instruction
Attachment 2- Caregiving Advertisement.docx Advertisement IC Document
Attachment 4a-4b - Caregiving Informed Consent.docx Informed Consent IC Document
Attachment 6- Thank You Letter.docx Thank You Letter IC Document
Attachment 7-Data Retention Policy.docx Data Retention Policy IC Document
Attachment 8- NCHS Non-Disclosure Affidavit.docx Non-Disclosure Affidavit IC Document
SSA_Caregiving 4.27.23_final.docx SSA IC Document
SSB_Caregiving 4.27.23.docx SSB IC Document

Information Collection (IC) Details

IC Title:	[NCHS] CCQDER's Caregiver	Agency IC Tracking Number:	0920-0222-23EN

IC Status: Unchanged

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	n/a	Caregiving Questions	Attachment 1-Caregiving Questions.docx	Yes	No	Fillable Fileable
Form and Instruction	n/a	Caregiving Screening Script	Attachment 3- Caregiving Screening Script.docx	No		Fillable Fileable
Form and Instruction	n/a	Respondent Data Collection Sheet	Attachment 5- Respondent Data Collection Sheet.docx	Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 45	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Previously Approved
Annual Number of Responses for this IC	45	45
Annual IC Time Burden (Hours)	35	35
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Advertisement	Attachment 2- Caregiving Advertisement.docx	05/03/2023
Informed Consent	Attachment 4a-4b - Caregiving Informed Consent.docx	05/03/2023
Thank You Letter	Attachment 6- Thank You Letter.docx	05/03/2023
Data Retention Policy	Attachment 7-Data Retention Policy.docx	05/03/2023
Non-Disclosure Affidavit	Attachment 8- NCHS Non-Disclosure Affidavit.docx	05/03/2023
SSA	SSA_Caregiving 4.27.23_final.docx	05/03/2023
SSB	SSB_Caregiving 4.27.23.docx	05/03/2023

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