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[nchs] Collaborating Center For Questionnaire Design And Evaluation Research
[NCHS] Collaborating Center for Questionnaire Design and Evaluation Research
OMB: 0920-0222
IC ID: 260045
OMB.report
HHS/CDC
OMB 0920-0222
ICR 202504-0920-019
IC 260045
( )
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 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
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 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 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
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
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
URL
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
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
330
0
0
0
0
330
Annual IC Time Burden (Hours)
102
0
0
0
0
102
Annual IC Cost Burden (Dollars)
0
0
0
0
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.