California Health Interview Survey 2007

Forms and Documents

Document Name	Status
Form 1 California Health Interview Survey 2007 Form	New
Form 1(Updated) California Health Interview Survey 2007 Form	New
Attach 6_Confidentiality Certificate.pdf Supplementary Document	2007-05-22
Attach 6 UCLA IRB Approval.pdf Supplementary Document	2007-05-22
Attach 5_Update CHIS 2007 QUESTIONNAIRE.pdf Supplementary Document	2007-05-22
Attach 4_CHIS 2007 Update Screener Refusal Letter In-person.doc Supplementary Document	2007-05-22
Attach 4_CHIS 2007 Update Advance Letter_In-person.doc Supplementary Document	2007-05-22
CaliforniaHealthInterviewSurvey2007_2-7-07_sectB[1].doc Supporting Statement B	0000-00-00
CaliforniaHealthInterviewSurvey2007_2-7-07_sectA[1].doc Supporting Statement A	0000-00-00

IC Document Collections

IC ID	Document Title	Status
178950	California Health Interview Survey 2007 Form	New
178949	California Health Interview Survey 2007 Form	New

ICR Details

OMB Control No: 0925-0578	ICR Reference No: 200703-0925-002
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/NIH	Agency Tracking No:
Title: California Health Interview Survey 2007
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 06/05/2007
	Date Received in OIRA: 03/07/2007
Terms of Clearance: This ICR is approved using the revised 2nd race/ethnicity question, as agreed by NCI/NIH. As discussed, the revised and approved 2nd race/ethnicity question will be phrased in a more open-ended fashion and will first ask respondents IF they identify with any one particular race or ethnicity before asking WHICH particular race/ethnicity they identify with. Though QA07_1.14 was the item specifically discussed, NIH/NCI will make these same revisions throughout the instruments, wherever this 2nd race/ethncity question appears.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2010	36 Months From Approved
Responses	52,165	0	0
Time Burden (Hours)	5,832	0	0
Cost Burden (Dollars)	0	0	0

---

Abstract: The NCI, along with other federal agencies, for a fourth time, is sponsoring a Cancer Control Module (CCM) to the California Health Interview Survey (CHIS) in 2007. The CCM will allow examination of various health and disease-related topics. The fourth bi-annual survey, CHIS 2007 is planned for administration to 48,000 adult and 4,000 adolescent Californian respondents.

---

Authorizing Statute(s): US Code: 42 USC 285 Name of Law: Cancer Control Programs
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	71 FR 175	09/11/2006
30-day Notice:	Federal Register Citation:	Citation Date:
	72 FR 4520	01/31/2007
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 2

IC Title	Form No.	Form Name
California Health Interview Survey 2007	1, 1(Updated)	Survey (Updated) ,   Survey
California Health Interview Survey 2007	1, 1 (Updated)	Survey ,   Survey (Updated)

---

ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	52,165	0	0	52,165	0	0
Annual Time Burden (Hours)	5,832	0	0	5,832	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: New Collection

---

Annual Cost to Federal Government: $1

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

Is this ICR related to the Pandemic Response? Uncollected

---

Common Form ICR:  No

---

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 03/07/2007

---