Trust, Acceptance and Confidence in Vaccines and Vaccination Schedules

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⚠️ Notice: This information collection may be referencing outdated material.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
Trust, Acceptance and Confidence in Vaccines and Vaccination Schedules Form and Instruction
Focus Group Screener Attachment 3 - FG Screener.docx Form and Instruction
Cognitive Interview Screener Attachment 4 - Cognitive Interview Screener.docx Form and Instruction
Focus Group Moderator Guide Attachment 1 - FG Moderator Guide.docx Form and Instruction
Cognitive Interview Moderator Guide Attachment 2 - Draft Questionnaire Domains.docx Form and Instruction
Attachment 5 - FG Informed Consent.docx Focus Group Informed Consent IC Document
Attachment 6 - Cognitive Interview Informed Consent.docx Cognitive Interview Informed Consent IC Document
Attachment 7 - Data Collection Sheet.docx Data Collection Sheet IC Document
Attachment 8 - FG Special Consent.docx Focus Group - Audio/Visual Consent IC Document
Attachment 9 - Cognitive Interview Special Consent.docx Cognitive Interview Audio/Visual Consent IC Document
Vaccine 10-day letter_06 30 2016.docx GenIC - 10-Day Letter IC Document

Information Collection (IC) Details

IC Title:	Trust, Acceptance and Confidence in Vaccines and Vaccination Schedules	Agency IC Tracking Number:	16AUF

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	NA	Focus Group Screener	Attachment 3 - FG Screener.docx	NA	Yes	Yes	Fillable Fileable
Form and Instruction	NA	Cognitive Interview Screener	Attachment 4 - Cognitive Interview Screener.docx	NA	Yes	Yes	Fillable Fileable
Form and Instruction	NA	Focus Group Moderator Guide	Attachment 1 - FG Moderator Guide.docx	NA	Yes	Yes	Fillable Fileable
Form and Instruction	NA	Cognitive Interview Moderator Guide	Attachment 2 - Draft Questionnaire Domains.docx	NA	Yes	Yes	Fillable Fileable

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: 258	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	258	258
Annual IC Time Burden (Hours)	124	124
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Focus Group Informed Consent	Attachment 5 - FG Informed Consent.docx	07/05/2016
Cognitive Interview Informed Consent	Attachment 6 - Cognitive Interview Informed Consent.docx	07/05/2016
Data Collection Sheet	Attachment 7 - Data Collection Sheet.docx	07/05/2016
Focus Group - Audio/Visual Consent	Attachment 8 - FG Special Consent.docx	07/05/2016
Cognitive Interview Audio/Visual Consent	Attachment 9 - Cognitive Interview Special Consent.docx	07/05/2016
GenIC - 10-Day Letter	Vaccine 10-day letter_06 30 2016.docx	07/05/2016

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