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[NCHS] CCQDER's Caregiver
[NCHS] Collaborating Center for Questionnaire Design and Evaluation Research
OMB: 0920-0222
IC ID: 260017
OMB.report
HHS/CDC
OMB 0920-0222
ICR 202504-0920-019
IC 260017
( )
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
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:
Document Type
Form No.
Form Name
Instrument File
URL
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
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 %
Requested
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
45
0
0
0
0
45
Annual IC Time Burden (Hours)
35
0
0
0
0
35
Annual IC Cost Burden (Dollars)
0
0
0
0
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.