Information Collection

[NCHS] CCQDER - Questions to Identify People with Intellectual and Developmental Disabilities at Point-of-Care Settings

IC 276212 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⚠️ Notice: This information collection may be referencing outdated material.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
Screening Script [NCHS] CCQDER - Questions to Identify People with Intellectual and Developmental Disabilities at Point-of-Care Settings	Form and Instruction
Questions to be Cognitively Tested [NCHS] CCQDER - Questions to Identify People with Intellectual and Developmental Disabilities at Point-of-Care Settings	Form and Instruction
Respondent Data Collection Sheet [NCHS] CCQDER - Questions to Identify People with Intellectual and Developmental Disabilities at Point-of-Care Settings	Form and Instruction
Screening Script Attachment 4 -Screening Script.docx	Form and Instruction
Questions to be Cognitively Tested Attachment 1 - Questions.docx	Form and Instruction
Respondent Data Collection Sheet Attachment 6 - In Person & Virtual Respondent Data Collection Sheet.docx	Form and Instruction
Attachment 2 - Purpose and Development of Questions.docx Purpose and Development of Questions	IC Document
Attachment 3a - Advertisement 1.docx Advertisement 1	IC Document
Attachment 3b - Advertisement 2.docx Advertisement 2	IC Document
Attachment 3c - Advertisement 3.docx Advertisement 3	IC Document
Attachment 3d - Advertisement 4.docx Advertisement 4	IC Document
Attachment 3e - Advertisement 5.docx Advertisement 5	IC Document
Attachment 5 - In Person & Virtual Informed Consent Forms.docx Informed Consent Forms	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 9 - NCHS Non-Disclosure Affidavit.docx NCHS Non-Disclosure Affidavit	IC Document
Attachment 10- IDD POC Cognitive Interview IRB Approval Letter.pdf Research Determination	IC Document
SSA IDD Point of Care Cognitive Interviews.docx SSA	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

[NCHS] CCQDER - Questions to Identify People with Intellectual and Developmental Disabilities at Point-of-Care Settings

Agency IC Tracking Number:

0920-25-0115

IC Status: New

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	n/a	No		Fillable Fileable
Form and Instruction	n/a	Yes	Yes	Fillable Fileable
Form and Instruction	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:

FR Citation:

Number of Respondents: 225

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 90 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	225	225
Annual IC Time Burden (Hours)	72	72
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Purpose and Development of Questions		07/07/2025
Advertisement 1		07/07/2025
Advertisement 2		07/07/2025
Advertisement 3		07/07/2025
Advertisement 4		07/07/2025
Advertisement 5		07/07/2025
Informed Consent Forms		07/07/2025
Thank You Letter		07/07/2025
Data Retention Policy		07/07/2025
NCHS Non-Disclosure Affidavit		07/07/2025
Research Determination		07/07/2025
SSA		07/07/2025

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

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