Information Collection

[NCHS] CCQDER's Caregiver

IC 260017 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⚠️ Notice: This information collection may be referencing outdated material.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
[NCHS] CCQDER's Caregiver	Form and Instruction
Caregiving Questions [NCHS] CCQDER's Caregiver	Form and Instruction
Caregiving Screening Script [NCHS] CCQDER's Caregiver	Form and Instruction
Respondent Data Collection Sheet [NCHS] CCQDER's Caregiver	Form and Instruction
Caregiving Questions Attachment 1-Caregiving Questions.docx	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
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
Respondent Data Collection Sheet Attachment 5- Respondent Data Collection Sheet.docx	Form and Instruction
Attachment 2- Caregiving Advertisement.docx Advertisement	IC Document
Attachment 2- Caregiving Advertisement.docx Advertisement	IC Document
Attachment 4a-4b - Caregiving Informed Consent.docx Informed Consent	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 6- Thank You Letter.docx Thank You Letter	IC Document
Attachment 7-Data Retention Policy.docx Data Retention Policy	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
Attachment 8- NCHS Non-Disclosure Affidavit.docx Non-Disclosure Affidavit	IC Document
SSA_Caregiving 4.27.23_final.docx SSA	IC Document
SSA_Caregiving 4.27.23_final.docx SSA	IC Document
SSB_Caregiving 4.27.23.docx SSB	IC Document
SSB_Caregiving 4.27.23.docx SSB	IC Document

Information Collection (IC) Details

View Information Collection (IC)

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:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	n/a	Yes	No	Fillable Fileable
Form and Instruction	n/a	No		Fillable Fileable
Form and Instruction	n/a	Yes	No	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: 45

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	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

table that charts IC Documents
Title	Document	Date Uploaded
Advertisement		05/03/2023
Informed Consent		05/03/2023
Thank You Letter		05/03/2023
Data Retention Policy		05/03/2023
Non-Disclosure Affidavit		05/03/2023
SSA		05/03/2023
SSB		05/03/2023

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

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