Information Collection

[HCHS] Cognitive Evaluation of Questions on Overdose and Substance Use Disorder and RANDS 12

IC 277332 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⚠️ Notice: This information collection may be referencing outdated material.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 [HCHS] Cognitive Evaluation of Questions on Overdose and Substance Use Disorder and RANDS 12	Form and Instruction
Data Collection Sheet [HCHS] Cognitive Evaluation of Questions on Overdose and Substance Use Disorder and RANDS 12	Form and Instruction
Questions to be Cognitively Tested [HCHS] Cognitive Evaluation of Questions on Overdose and Substance Use Disorder and RANDS 12	Form and Instruction
RANDS 12 Questionnaire [HCHS] Cognitive Evaluation of Questions on Overdose and Substance Use Disorder and RANDS 12	Form and Instruction
Screening Script Attachment 4 - Screening Script.docx	Form and Instruction
Data Collection Sheet Attachment 9 - Data Collection Sheet.docx	Form and Instruction
Questions to be Cognitively Tested Attachment 1a - Questions to be cognitively tested.docx	Form and Instruction
RANDS 12 Questionnaire Attachment 1b - RANDS 12 Instrument - V2.docx	Form and Instruction
Attachment 3a - Advertisement OSUD.docx Advertisement 1	IC Document
Attachment 3b - Advertisement OSUD.docx Advertisement 2	IC Document
Attachment 5 - Informed Consent.docx Informed Consent	IC Document
Attachment 6 - NCHS Non-Disclosure Affidavit.docx NCHS Non-Disclosure Affidavit	IC Document
Attachment 7 - Data Storage and Access Policy_final.docx Data Storage and Access Policy	IC Document
Attachment 8 - Thank You Letter.docx Thank You Letter	IC Document
Attachment 10 IRB Determination.pdf Research Determination	IC Document
Supporting Statement A - NHANES OSUD & RANDS 12_8.4.2025.docx SSA	IC Document
Attachment 2 - Previous use and development_V4.docx Previous Use and development	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

[HCHS] Cognitive Evaluation of Questions on Overdose and Substance Use Disorder and RANDS 12

Agency IC Tracking Number:

0920-25-0169

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	Yes	Yes	Fillable Fileable
Form and Instruction	n/a	Yes	Yes	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: 11,775

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	11,775	11,775
Annual IC Time Burden (Hours)	3,923	3,923
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Advertisement 1		08/29/2025
Advertisement 2		08/29/2025
Informed Consent		08/29/2025
NCHS Non-Disclosure Affidavit		08/29/2025
Data Storage and Access Policy		08/29/2025
Thank You Letter		08/29/2025
Research Determination		08/29/2025
SSA		08/29/2025
Previous Use and development		12/08/2025

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

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