NCHS Questionnaire Design Research Laboratory

Forms and Documents

Document Name	Status
Form 0920-0222 CQDER - Opioid Plus Card Sort Form and Instruction	New
Cognitive Interviewing Study of Opioid-Related Questions (Spanish Version) Form and Instruction	New
Form 0920-0222 Collaborating Center for Questionnaire Design and Evaluation Research (CCQDER) Form and Instruction	New
Cognitive Interviewing Study of Opioid-Related Questions Form and Instruction	New
Questionnaire Design and Evaluation Research on Injury for the National Health Interview Survey (NHIS) Form and Instruction	New
Cognitive Testing of Questions on Teen Alcohol and Marijuana Use Form and Instruction	New
Form 092017AUC Cognitive Testing of NHIS health care utilization smoking, and selected child questions Form and Instruction	New
Form 0920-0222 Cognitive Testing of Impaired Driving Questions for CDC National Center for Injury Prevention and Control (NPIPC) Form and Instruction	New
Cognitive Testing of Middle Eastern North African (MENA) Questions Form	New
Spanish Cognitive Study to Examine Traumatic Brain Injury Questions Form	New
Trust, Acceptance and Confidence in Vaccines and Vaccination Schedules Form and Instruction	New
Evaluation of Traumatic Brain Injury Questions for CDC's National Center for Injury Prevention and Control (NCIPC) Form and Instruction	New
2016 CDC Healthcare Systems Scorecard (HSSC) Assessment Tool for Primary Care Practices Form	New
Testing of questions on cognitive functioning and other questions for the National Health Interview Survey (NHIS) Form and Instruction	New
PRAMS - English Form	New
Form 0920-0222 2017 NHANES Health Behaviors Cognitive Interviewing Study/Spanish Form and Instruction	New
PRAMS Phase 8 - Spanish Form	New
Form 0920-0222 (16AG) 2017 NHANES Health Behaviors Cognitive Interviewing Study Form and Instruction	New
RANDS Form	New
Att O Explain cog interview.doc Supplementary Document	2015-06-11
Att N Resp data collect sheet.doc Supplementary Document	2015-06-11
Att M Sample advance letter.doc Supplementary Document	2015-06-11
Att L QDRL Voice mail script.doc Supplementary Document	2015-06-11
Att K Sample newspaper adv.doc Supplementary Document	2015-06-11
Att J Sample flyer.doc Supplementary Document	2015-06-11
Att I IRB approval.rtf Supplementary Document	2015-06-11
Att H Spec consent for fg.docx Supplementary Document	2015-06-11
Att G Spec consent 4offsite research.doc Supplementary Document	2015-06-11
Supp Statement A 060815.docx Supporting Statement A	2015-06-11
Att F Spec consent.docx Supplementary Document	2015-06-11
Att E informed consent.doc Supplementary Document	2015-06-11
Att D screening script.doc Supplementary Document	2015-06-11
Att C nondisclosure affidavit.doc Supplementary Document	2015-06-11
Attach B 60day Fed Reg Notice.pdf Supplementary Document	2015-06-11
Att A Pub Health Serv Act.doc Supplementary Document	2015-06-11
Supp Statement B 052815.doc Supporting Statement B	2015-06-11

IC Document Collections

IC ID	Document Title	Status
231689	CQDER - Opioid Plus Card Sort Form and Instruction	New
231500	Cognitive Interviewing Study of Opioid-Related Questions (Spanish Version) Form and Instruction	New
231481	Collaborating Center for Questionnaire Design and Evaluation Research (CCQDER) Form and Instruction	New
231306	Cognitive Interviewing Study of Opioid-Related Questions Form and Instruction	New
230189	NHANES Contact and Message Testing Other-ord	New
229901	Research and Development Survey (RANDS) Cognitive Interviewing Sub-Study Other-WORD	New
229527	Cognitive Testing of ASPE Criminal Justice System Questions Other-WORD	New
229163	Cognitve Testing of Food for Babies and Mothers' Health Question on the NHANES B24 Month Questionnaire Other-WORD	New
228813	Questionnaire Design and Evaluation Research on Injury for the National Health Interview Survey (NHIS) Form and Instruction	New
228398	Cognitive Testing of National Survey of Hospital-Based Victim Services (NSHVS) Other-Telephone script	New
228379	Cognitive Testing of Questions on Teen Alcohol and Marijuana Use Form and Instruction	New
227302	Cognitive Testing of NHIS health care utilization smoking, and selected child questions Form and Instruction	New
226479	Cognitive Testing of Impaired Driving Questions for CDC National Center for Injury Prevention and Control (NPIPC) Form and Instruction	New
224421	Cognitive Testing of Middle Eastern North African (MENA) Questions Form	New
223727	Cognitive testing of Confidentiality Pledge, Round 2 Other-WORD	New
223623	Labor Force Module of Persons with Disabilities Round 2 Other-WORD	New
223018	Spanish Cognitive Study to Examine Traumatic Brain Injury Questions Form	New
222327	Trust, Acceptance and Confidence in Vaccines and Vaccination Schedules Form and Instruction	New
221825	Congitive Testing of Confidentiality Pledges Other-Testing Materials	New
221813	Evaluation of Traumatic Brain Injury Questions for CDC's National Center for Injury Prevention and Control (NCIPC) Form and Instruction	New
221510	2017 NHANES Health Behaviors Cognitive Interviewing Study Other-WORD	New
221257	Center for Questionnaire Design and Evaluation Research (CQDER) CMS 10-day Letter Instruction	New
221137	2016 CDC Healthcare Systems Scorecard (HSSC) Assessment Tool for Primary Care Practices Form	New
220340	Testing of questions on cognitive functioning and other questions for the National Health Interview Survey (NHIS) Form and Instruction	New
220016	GenIC UNICEF/Washington Group School Environment Evaluation Study 2016 Other-WORD	New
219197	PRAMS - English Form	New
219178	Labor Force Module of Persons with Disabilities Other-Telephone Screener	New
218756	2017 NHANES Health Behaviors Cognitive Interviewing Study/Spanish Form and Instruction	New
218569	PRAMS Phase 8 - Spanish Form	New
218517	2017 NHANES Health Behaviors Cognitive Interviewing Study Form and Instruction	New
218109	RANDS Form	New

ICR Details

OMB Control No: 0920-0222	ICR Reference No: 201506-0920-003
Status: Historical Active	Previous ICR Reference No: 201205-0920-001
Agency/Subagency: HHS/CDC	Agency Tracking No:
Title: NCHS Questionnaire Design Research Laboratory
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 07/21/2015
	Date Received in OIRA: 06/19/2015
Terms of Clearance: CDC will continue to submit individual collections under this generic clearance to OMB. OMB will strive to provide feedback on the individual collections within ten working days, whenever possible, as is currently the case. Standard remuneration of respondents for cognitive testing is $40.00. Higher remunerations may be requested with justification for difficult recruitments, focus groups, etc.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2018	36 Months From Approved	07/31/2015
Responses	24,000	0	9,300
Time Burden (Hours)	13,150	0	9,450
Cost Burden (Dollars)	0	0	0

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Abstract: The revision requested consists of an increase in burden hours for the next 3-year approval period. The purpose and use of collecting this information fall into five categories: 1) Development and testing of specific survey questionnaires; 2) Research on the cognitive and interpretive aspects of survey methodology; 3) Research on human-computer interfaces/usability; 4) Field tests/Pilot interviewing; and 5) Studies of the optimal design and presentation of statistical graphical and textual material. Methods for data collection include interviewer administered, self-administered, telephone, Computer Assisted Personal Interviewing (CAPI) and Computer Assisted Self-Interviewing (CASI), Audio Computer-Assisted Self-Interviewing (ACASI), and web-based questionnaires including: cognitive interviewing, focus groups, usability testing, and field tests/pilot household interviews.

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

Citations for New Statutory Requirements: None

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

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 13868	03/17/2015
30-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 34644	06/17/2015
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 31

IC Title	Form No.	Form Name
2017 NHANES Health Behaviors Cognitive Interviewing Study	0920-0222 (16AG), 0920-0222 (16AG), 0920-0222 (16AG) , 0920-0222 (16AG), 0920-0222 (16AG)	Appendix 3 - NHANES Screener 090215 ,   Appendix 1 - NHANES Questions for Cognitive Testing ,   Appendix 2a&b - NHANES Adv Flyer ,   Appendix 4 - NHANES Informed Consent ,   Appendix 5 - Special Consent
Cognitive Testing of NHIS health care utilization smoking, and selected child questions	092017AUC, 0920-17AUC	Attach 3 Telephone Screener vcb 051017kw no confid pld update ,   Attach 3 Telephone Screener vcb 051017kw no confid pld update
Research and Development Survey (RANDS) Cognitive Interviewing Sub-Study
Center for Questionnaire Design and Evaluation Research (CQDER) CMS 10-day Letter	0920-16AEE, 0920-16AEE, 0920-16AEE	CQDER CMS Att 3ab Telephone Screener ,   CQDER CMS Att 5ab Resp Data Collect ,   CQDER CMS Att 1ab Qnne wshowcards
Questionnaire Design and Evaluation Research on Injury for the National Health Interview Survey (NHIS)	NA, NA	Questionnaire - Injury Questions to Evaluate ,   Telephone Screener
Collaborating Center for Questionnaire Design and Evaluation Research (CCQDER)	0920-0222, 0920-0222, 0920-0222, 0920-0222	National Study of Long-Term Care Provider 2016 Adult Day Services Center Questionnaire ,   Adult Day Care Services Center (ADSC) Telephone Screening Script ,   Residential Care Community (RCC) Telephone Screening Script ,   National Study of Long-Term Care Providers 2016 Residential Care Community Questionnaire
Cognitive Testing of Impaired Driving Questions for CDC National Center for Injury Prevention and Control (NPIPC)	0920-0222, 0920-0222	Imp Driving - Attach 3 Screener rev-kw ,   Imp Driving - Attach 5 Resp Data Collection Sheet
Cognitive Interviewing Study of Opioid-Related Questions	n/a, n/a, n/a	Questionnaire for Cognitive Testing of Opioid Questions ,   Telephone Screener for Individuals Recruited through the Newspaper Ad ,   Respondent Data Collection Sheet (completed during the cognitive interview)
2017 NHANES Health Behaviors Cognitive Interviewing Study/Spanish	0920-0222, 0920-0222, 0920-0222, 0920-0222	Appendix 1 Questionnaire Spanish NHANES 100215 ,   Appendix 2a&b Ad&Flyer Spanish NHANES ,   Appendix 3 Telephone Screener Spanish NHANES 100215 ,   Appendix 5 Resp Data Collection Sheet Spanish NHANES
Labor Force Module of Persons with Disabilities
NHANES Contact and Message Testing
Cognitive Testing of National Survey of Hospital-Based Victim Services (NSHVS)	none, none	National Survey of Hospital-based Victim Services ,   Respondent Data Sheet
Testing of questions on cognitive functioning and other questions for the National Health Interview Survey (NHIS)	NA, NA	NHIS Cognitive Functioning and other questions to be cognitively tested ,   Telephone Screening Script
Cognitive Testing of ASPE Criminal Justice System Questions
Cognitive Interviewing Study of Opioid-Related Questions (Spanish Version)	n/a, n/a, n/a	Sample screening script for respondent contact Cognitive interviewing study of opioid use and pain questions ,   Spanish Questions to be cognitively tested ,   Spanish Respondent Data Collection Sheet
Labor Force Module of Persons with Disabilities Round 2	1	Questionnaire
Cognitive Testing of Middle Eastern North African (MENA) Questions	None, None, None	Questions to be cognitively tested ,   Telephone screening script ,   Respondent data collection sheet
Congitive Testing of Confidentiality Pledges	none	Respondent data collection sheet
Cognitive Testing of Questions on Teen Alcohol and Marijuana Use	NA, NA	Telephone Screening Script- Cognitive Testing of Questions on Teen Alcohol and Marijuana Use ,   Teen Alcohol and Marijuana Use Questions to be Cognitively Tested
Cognitve Testing of Food for Babies and Mothers' Health Question on the NHANES B24 Month Questionnaire
GenIC UNICEF/Washington Group School Environment Evaluation Study 2016
2017 NHANES Health Behaviors Cognitive Interviewing Study
Evaluation of Traumatic Brain Injury Questions for CDC's National Center for Injury Prevention and Control (NCIPC)	NA, NA	Questions to be Cognitively Tested ,   Telephone Screening Script for Adult/Self-Responder or Adult Proxy for Child 5-17
RANDS	none, none, none, none	Telephone Screener ,   Interview Questionnaire ,   Web Intro Screen ,   Respondent Demographic Data
PRAMS - English	none, none	PRAMS Phase 8 Supplemental Questions ,   PRAMS screener
Spanish Cognitive Study to Examine Traumatic Brain Injury Questions	none, none, none	Spanish Questions - TBI ,   Spanish Telephone Screener ,   Spanish Data Collection Sheet
Cognitive testing of Confidentiality Pledge, Round 2
PRAMS Phase 8 - Spanish	none, none, none	PRAMS Phase 8 - Spanish ,   Screener ,   Respondent Data Sheet
Trust, Acceptance and Confidence in Vaccines and Vaccination Schedules	NA, NA, NA, NA	Focus Group Screener ,   Cognitive Interview Screener ,   Focus Group Moderator Guide ,   Cognitive Interview Moderator Guide
2016 CDC Healthcare Systems Scorecard (HSSC) Assessment Tool for Primary Care Practices	none, none, none	Screener ,   Interview Questionnaire ,   Demographic Sheet
CQDER - Opioid Plus Card Sort	0920-0222, 0920-0222	Opioid Questionnaire - Card Sort ,   Telephone Screener

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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	24,000	9,300	0	14,700	0	0
Annual Time Burden (Hours)	13,150	9,450	0	3,700	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: CDC is requesting an increase in burden hours and respondents due to anticipated increase in the number and size of projects planned during the next 3 years.

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Annual Cost to Federal Government: $1,801,033

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]? No

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

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Common Form ICR:  No

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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: 06/19/2015

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