National Health Interview Survey

Forms and Documents

Document Name	Status
Followback Survey Questionnaire Form	Modified
Reinterview Survey Form and Instruction	Unchanged
New Supplements and Core Changes Form and Instruction	Unchanged
Sample Child Core Questionnaire Form and Instruction	Unchanged
Sample Adult Core Questionnaire Form and Instruction	Unchanged
Family Core Questionnaire Form and Instruction	Unchanged
OMB Statement and Screener Form and Instruction	Unchanged
0920-0214 Follow-Back Description ltr 040315 sig.docx Justification for No Material/Nonsubstantive Change	2015-04-27

IC Document Collections

IC ID	Document Title	Status
214142	Followback Survey Questionnaire Form	Modified
214116	Reinterview Survey Form and Instruction	Unchanged
214115	New Supplements and Core Changes Form and Instruction	Unchanged
214114	Sample Child Core Questionnaire Form and Instruction	Unchanged
214113	Sample Adult Core Questionnaire Form and Instruction	Unchanged
214112	Family Core Questionnaire Form and Instruction	Unchanged
214111	OMB Statement and Screener Form and Instruction	Unchanged

ICR Details

OMB Control No: 0920-0214	ICR Reference No: 201504-0920-008
Status: Historical Active	Previous ICR Reference No: 201503-0920-009
Agency/Subagency: HHS/CDC	Agency Tracking No: 15ZM
Title: National Health Interview Survey
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 05/07/2015
	Date Received in OIRA: 05/01/2015
Terms of Clearance: CDC/NCHS may use the non-substantive change mechanism to modify existing questions, including those designed to add depth/additional detail and cycle in and out supplemental modules that have been used in the past years (with modest updates). If new supplemental modules, new questionnaire instruments, or modifications to the sample are anticipated, a full revision of the ICR package must be submitted to OMB. The results of the incentive experiment should be shared with OMB when available.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2017	12/31/2017	12/31/2017
Responses	163,400	0	167,000
Time Burden (Hours)	47,633	0	48,833
Cost Burden (Dollars)	0	0	0

---

Abstract: The Centers for Disease Control and Prevention and the National Center for Health Statistics is requesting changes to the National Health Interview Survey 2015 Follow-back Survey.

---

Authorizing Statute(s): US Code: 42 USC 242 Name of Law: Public Health Service Act
  

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:
	79 FR 52343	09/03/2014
30-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 71432	12/02/2014
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 7

IC Title	Form No.	Form Name
New Supplements and Core Changes	None	2015 New Supplements and Core Changes
Reinterview Survey	None	2015 Reinterview Survey
OMB Statement and Screener	None	2015 OMB Statement and Screener
Sample Adult Core Questionnaire	None	2015 Sample Adult Core Questionnaire
Followback Survey Questionnaire	None	2015 Follow-back Survey
Family Core Questionnaire	None	2015 Family Core Questionnaire
Sample Child Core Questionnaire	None	2015 Sample Child Core Questionnaire

---

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	163,400	167,000	0	-3,600	0	0
Annual Time Burden (Hours)	47,633	48,833	0	-1,200	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

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

Burden Increase Due to:

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

Burden Reduction Due to: Miscellaneous Actions

Short Statement: A reduction in the size sample for the 2015 Follow-back survey results in a reduction of burden hours for that data collection instrument.

---

Annual Cost to Federal Government: $42,000,000

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]? Yes

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

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: 05/01/2015

---