Rands

NCHS Questionnaire Design Research Laboratory

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0222 can be found here:

Documents and Forms

Document Name Document Type
RANDS Form
Telephone Screener Appendix 3ab - Telephone Screeners-final.docx Form
Interview Questionnaire Appendix 1 - Interviewer Administered Questionnaire rev.docx Form
Web Intro Screen Appendix 6 - Web Introduction Screen.docx Form
Respondent Demographic Data Demographic Info.doc Form
Appendix 7 - Gallup Data Protection and Security Overview 2015.pdf Gallup Data Protection IC Document
Appendix 4 - Informed Consent-final.docx Informed Consent IC Document
Appendix 2 - Cog Int Adv&flyer.docx Ad/Flyier IC Document
OMB 10 Day Letter_RAND_0826 2015.docx Supporting Statement IC Document
Appendix 5 - Special Consent rev2.docx Special Consent IC Document

Information Collection (IC) Details

IC Title:	RANDS	Agency IC Tracking Number:	15BFA

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	none	Telephone Screener	Appendix 3ab - Telephone Screeners-final.docx	Yes	Yes	Fillable Fileable
Form	none	Interview Questionnaire	Appendix 1 - Interviewer Administered Questionnaire rev.docx	No		Paper Only
Form	none	Web Intro Screen	Appendix 6 - Web Introduction Screen.docx	Yes	Yes	Fillable Fileable
Form	none	Respondent Demographic Data	Demographic Info.doc	No		Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title: 09-20-0164 Health and Demographic Surveys Conducted in Probability Samples of the U.S. Population	FR Citation: 49 FR 37693

Number of Respondents: 4,132	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 60 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	4,132	4,132
Annual IC Time Burden (Hours)	1,399	1,399
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Gallup Data Protection	Appendix 7 - Gallup Data Protection and Security Overview 2015.pdf	09/08/2015
Informed Consent	Appendix 4 - Informed Consent-final.docx	09/08/2015
Ad/Flyier	Appendix 2 - Cog Int Adv&flyer.docx	09/08/2015
Supporting Statement	OMB 10 Day Letter_RAND_0826 2015.docx	09/08/2015
Special Consent	Appendix 5 - Special Consent rev2.docx	09/18/2015

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