Document
Respondent Data Collection Sheet
ICR 202609-0920-001 · OMB 0920-0214 · Object 172427500.
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Document Metadata
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
|---|---|
| File Title | Respondent Data Collection Sheet |
| Author | Titus, Amanda (CDC/DDPHSS/NCHS/DRM) |
| Last Modified By | Writer |
| File Modified | 2026-09-03 |
| File Created | 2026-09-05 |
| Conversion State | complete |
Extracted Text
Attachment 6: Respondent Data Collection Sheet (face-to-face interviews conducted at NCHS or off-site) Form Approved OMB No. 0920-0214 Exp. Date: 12/31/2026 Notice—CDC estimates the average public reporting burden for this collection of information as 5 minutes per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS H21-8, Atlanta, Georgia 30333; ATTN: PRA (0920-0214). Assurance of Confidentiality: We take your privacy very seriously. All information that relates to or describes identifiable characteristics of individuals, a practice, or an establishment will be used only for statistical purposes. NCHS staff, contractors, and agents will not disclose or release responses in identifiable form without the consent of the individual or establishment in accordance with section 308(d) of the Public Health Service Act (42 U.S.C. 242m(d)) and the Confidential Information Protection and Statistical Efficiency Act or CIPSEA (44 U.S.C. 3561-3583). In accordance with CIPSEA, every NCHS employee, contractor, and agent has taken an oath and is subject to a jail term of up to five years, a fine of up to $250,000, or both if he or she willfully discloses ANY identifiable information about you. In addition to the above cited laws, NCHS complies with the Federal Cybersecurity Enhancement Act of 2018 (6 U.S.C. § 663) which protects Federal information systems from cybersecurity risks by screening their networks. DEPARTMENT OF HEALTH & HUMAN SERVICES Public Health Service Centers for Disease Control and Prevention National Center for Health Statistics 3311 Toledo Road Hyattsville, Maryland 20782 Respondent Data Collection Sheet This form asks for basic information about you. At the end of the study, your information will be combined with information from other people in the study and will help us form a picture of the characteristics of the people who participated in our study. For our records we would appreciate it if you would take a minute to fill out this form. 1. How did you hear about us? ___________ 2. Are you? Male Female 3. What is your age? _________ 5. Are you Hispanic or Latino? Yes No 6. What is your race? Mark one or more races to indicate what you consider yourself to be. American Indian or Alaska Native Asian Black or African American Native Hawaiian or other Pacific Islander White 7. What is the highest level of school you have completed? Less than High School (No Diploma or GED) High School Diploma or GED Associate Degree Some College Bachelor’s Degree Graduate Degree 8. Are you currently employed? Yes No 9. What is your total household income? $0-19,999 $20,000-$44,999 $45,000-$79,999 $80,000 or more