Information Collection

CCQDER - Questions on Subjective Cognitive Decline

IC 269389 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⚠️ Notice: This information collection may be referencing outdated material.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

Document Name Document Type
Form 0920-0222 CCQDER - Questions on Subjective Cognitive Decline Form and Instruction
Form 0920-0222 Cognitive Decline - Screening Script CCQDER - Questions on Subjective Cognitive Decline Form and Instruction
Form 0920-0222 Questions to be Cognitively Tested CCQDER - Questions on Subjective Cognitive Decline Form and Instruction
Form 0920-0222 Respondent Data Collection Sheet CCQDER - Questions on Subjective Cognitive Decline Form and Instruction
0920-0222 Cognitive Decline - Screening Script Attachment 4 - Screening Script CD- Clean 7.12.24.docx Form and Instruction
0920-0222 Cognitive Decline - Screening Script Attachment 4 - Screening Script CD- Clean 7.12.24.docx Form and Instruction
0920-0222 Questions to be Cognitively Tested Attachment 1 Questions CD.docx Form and Instruction
0920-0222 Questions to be Cognitively Tested Attachment 1 Questions CD.docx Form and Instruction
0920-0222 Respondent Data Collection Sheet Attachment 6ab - (In Person & Virtual) Respondent Data Collection Sheet- CLEAN 7.12.24.docx Form and Instruction
0920-0222 Respondent Data Collection Sheet Attachment 6ab - (In Person & Virtual) Respondent Data Collection Sheet- CLEAN 7.12.24.docx Form and Instruction
Attachment 2- Purpose and Development of Questions CD- Clean 6.12.24.docx Purpose and Development of Cognitive Decline Questions IC Document
Attachment 2- Purpose and Development of Questions CD- Clean 6.12.24.docx Purpose and Development of Cognitive Decline Questions IC Document
Attachment 3ab- Suspected and Diagnosed Cog Decline Advertisements CD 6.5.24.docx Suspected and Diagnosed Cognitive Decline Advertisements IC Document
Attachment 3ab- Suspected and Diagnosed Cog Decline Advertisements CD 6.5.24.docx Suspected and Diagnosed Cognitive Decline Advertisements IC Document
Attachment 5ab - (In Person & Virutal) - Informed Consent Forms CD 6.5.24.docx Informed Consent Forms IC Document
Attachment 5ab - (In Person & Virutal) - Informed Consent Forms CD 6.5.24.docx Informed Consent Forms IC Document
Attachment 7 Thank You Letter.docx Thank You Letter IC Document
Attachment 7 Thank You Letter.docx Thank You Letter IC Document
Attachment 8 Data Retention Policy.docx Data Retention Policy IC Document
Attachment 8 Data Retention Policy.docx Data Retention Policy IC Document
Attachment 9 NCHS Non-Disclosure Affidavit- Clean 6.12.24.docx Non-Disclosure Affidavit IC Document
Attachment 9 NCHS Non-Disclosure Affidavit- Clean 6.12.24.docx Non-Disclosure Affidavit IC Document
Attachment 10- Distress Guide.docx Distress Guide IC Document
Attachment 10- Distress Guide.docx Distress Guide IC Document
Attachment 11- 7500 Exempt Research Approval Letter.pdf Exempt Research Determination IC Document
Attachment 11- 7500 Exempt Research Approval Letter.pdf Exempt Research Determination IC Document
Supporting Statement A CD 7.8.24 FINAL.docx Supporting Statement A / GenIC Template IC Document
Supporting Statement A CD 7.8.24 FINAL.docx Supporting Statement A / GenIC Template IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	CCQDER - Questions on Subjective Cognitive Decline	Agency IC Tracking Number:	0920-0222-24HK

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	Cognitive Decline - Screening Script	Attachment 4 - Screening Script CD- Clean 7.12.24.docx	N/A	No		Fillable Fileable
Form and Instruction	0920-0222	Questions to be Cognitively Tested	Attachment 1 Questions CD.docx	N/A	Yes	Yes	Fillable Fileable
Form and Instruction	0920-0222	Respondent Data Collection Sheet	Attachment 6ab - (In Person & Virtual) Respondent Data Collection Sheet- CLEAN 7.12.24.docx	N/A	Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title: Health and Demographic Surveys Conducted in Probability Samples of the U. S. Population 09-20-0164	FR Citation: 49 FR 37693

Number of Respondents: 120	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 50 %

	Requested	Previously Approved
Annual Number of Responses for this IC	120	120
Annual IC Time Burden (Hours)	35	35
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Purpose and Development of Cognitive Decline Questions	Attachment 2- Purpose and Development of Questions CD- Clean 6.12.24.docx	07/11/2024
Suspected and Diagnosed Cognitive Decline Advertisements	Attachment 3ab- Suspected and Diagnosed Cog Decline Advertisements CD 6.5.24.docx	07/11/2024
Informed Consent Forms	Attachment 5ab - (In Person & Virutal) - Informed Consent Forms CD 6.5.24.docx	07/11/2024
Thank You Letter	Attachment 7 Thank You Letter.docx	07/11/2024
Data Retention Policy	Attachment 8 Data Retention Policy.docx	07/11/2024
Non-Disclosure Affidavit	Attachment 9 NCHS Non-Disclosure Affidavit- Clean 6.12.24.docx	07/11/2024
Distress Guide	Attachment 10- Distress Guide.docx	07/11/2024
Exempt Research Determination	Attachment 11- 7500 Exempt Research Approval Letter.pdf	07/11/2024
Supporting Statement A / GenIC Template	Supporting Statement A CD 7.8.24 FINAL.docx	07/11/2024

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

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