Information Collection

[nchs] Collaborating Center For Questionnaire Design And Evaluation Research

IC 260045 under ICR 202504-0920-019 · OMB 0920-0222.

Documents and Forms

Document Name Document Type
Form 0920-0222-23EQ [NCHS] COLLABORATING CENTER FOR QUESTIONNAIRE DESIGN AND EVALUATION RESEARCH Form and Instruction
0920-0222-23EQ Attachment 5a-5b Respondent Data Collection Sheet 4.28.2 Attachment 5a-5b Respondent Data Collection Sheet 4.28.23.docx Form and Instruction
0920-0222-23EQ Attachment 5a-5b Respondent Data Collection Sheet 4.28.2 Attachment 5a-5b Respondent Data Collection Sheet 4.28.23.docx Form and Instruction
0920- 0222-23EQ Questions Attachment 1- PCE Questions 4.28.23.docx Form and Instruction
0920- 0222-23EQ Questions Attachment 1- PCE Questions 4.28.23.docx Form and Instruction
0920-0222-23EQ Screening Script Attachment 3a-3c- Screening Script 4.28.23.docx Form and Instruction
0920-0222-23EQ Screening Script Attachment 3a-3c- Screening Script 4.28.23.docx Form and Instruction
Attachment 2a-2c-Advertisement 4.5.23.docx Attachment 2a-2c-Advertisement 4.5.23 IC Document
Attachment 2a-2c-Advertisement 4.5.23.docx Attachment 2a-2c-Advertisement 4.5.23 IC Document
Attachment 4a-4f- Informed Consent 4.28.23.docx Attachment 4a-4f- Informed Consent 4.28.23 IC Document
Attachment 4a-4f- Informed Consent 4.28.23.docx Attachment 4a-4f- Informed Consent 4.28.23 IC Document
Attachment 6- PCE Thank You Letter.docx Attachment 6- PCE Thank You Letter IC Document
Attachment 6- PCE Thank You Letter.docx Attachment 6- PCE Thank You Letter IC Document
Attachment 7-Data Retention Policy.docx Attachment 7-Data Retention Policy IC Document
Attachment 7-Data Retention Policy.docx Attachment 7-Data Retention Policy IC Document
Attachment 8 -Distress guide.docx Attachment 8 -Distress guide IC Document
Attachment 8 -Distress guide.docx Attachment 8 -Distress guide IC Document
Attachment 9- NCHS Non-Disclosure Affidavit 4.28.23.docx Attachment 9- NCHS Non-Disclosure Affidavit 4.28.23 IC Document
Attachment 9- NCHS Non-Disclosure Affidavit 4.28.23.docx Attachment 9- NCHS Non-Disclosure Affidavit 4.28.23 IC Document
SSB-Childhood Experiences 4.28.23.docx SSB-Childhood Experiences 4.28.23 IC Document
SSB-Childhood Experiences 4.28.23.docx SSB-Childhood Experiences 4.28.23 IC Document
SSA-Childhood Experiences 5.31.23 Clean.docx Sup. Stmt. Part A: Childhood Experiences IC Document
SSA-Childhood Experiences 5.31.23 Clean.docx Sup. Stmt. Part A: Childhood Experiences 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:	0920-0222-23EQ

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	0920-0222-23EQ	Attachment 5a-5b Respondent Data Collection Sheet 4.28.23	Attachment 5a-5b Respondent Data Collection Sheet 4.28.23.docx	Yes	Yes	Fillable Fileable
Form and Instruction	0920- 0222-23EQ	Questions	Attachment 1- PCE Questions 4.28.23.docx	Yes	Yes	Fillable Fileable
Form and Instruction	0920-0222-23EQ	Screening Script	Attachment 3a-3c- Screening Script 4.28.23.docx	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: 330	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	330	330
Annual IC Time Burden (Hours)	102	102
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Attachment 2a-2c-Advertisement 4.5.23	Attachment 2a-2c-Advertisement 4.5.23.docx	05/05/2023
Attachment 4a-4f- Informed Consent 4.28.23	Attachment 4a-4f- Informed Consent 4.28.23.docx	05/05/2023
Attachment 6- PCE Thank You Letter	Attachment 6- PCE Thank You Letter.docx	05/05/2023
Attachment 7-Data Retention Policy	Attachment 7-Data Retention Policy.docx	05/05/2023
Attachment 8 -Distress guide	Attachment 8 -Distress guide.docx	05/05/2023
Attachment 9- NCHS Non-Disclosure Affidavit 4.28.23	Attachment 9- NCHS Non-Disclosure Affidavit 4.28.23.docx	05/05/2023
SSB-Childhood Experiences 4.28.23	SSB-Childhood Experiences 4.28.23.docx	05/05/2023
Sup. Stmt. Part A: Childhood Experiences	SSA-Childhood Experiences 5.31.23 Clean.docx	05/31/2023

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