Information Collection

[nchs] Collaborating Center For Questionnaire Design And Evaluation Research

IC 260045 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⚠️ Notice: This information collection may be referencing outdated material.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 0920-0222-23EQ [NCHS] COLLABORATING CENTER FOR QUESTIONNAIRE DESIGN AND EVALUATION RESEARCH	Form and Instruction
Form 0920-0222-23EQ Attachment 5a-5b Respondent Data Collection Sheet 4.28.23 [NCHS] COLLABORATING CENTER FOR QUESTIONNAIRE DESIGN AND EVALUATION RESEARCH	Form and Instruction
Form 0920- 0222-23EQ Questions [NCHS] COLLABORATING CENTER FOR QUESTIONNAIRE DESIGN AND EVALUATION RESEARCH	Form and Instruction
Form 0920-0222-23EQ Screening Script [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:

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

table that charts list of burden
	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

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

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

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