Collaborating Center for Questionnaire Design and Evaluation Research (CCQDER)

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⚠️ Notice: This information collection may be referencing outdated material.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
Form 0920-0222 Collaborating Center for Questionnaire Design and Evaluation Research (CCQDER) Form and Instruction
0920-0222 National Study of Long-Term Care Provider 2016 Adult Day Attach 1a - ADSC Questionnaire-v2 051418.pdf Form and Instruction
0920-0222 National Study of Long-Term Care Providers 2016 Resident Attach 1b - RCC Questionnaire-v2 051418.pdf Form and Instruction
0920-0222 Adult Day Care Services Center (ADSC) Telephone Screenin Attach 3a - ADSC Telephone Screener.docx Form and Instruction
0920-0222 Residential Care Community (RCC) Telephone Screening Scr Attach 3b - RCC Telephone Screener.docx Form and Instruction
LTCSB10-day letter 051418.docx LTCSB 10-day Letter IC Document
Attach 2 - Advance Letter.docx Att 2_Advance Letter IC Document
Attach 4 - Informed Consent.doc Att 4_Informed Consent IC Document
Attach 5 - Resp Data Collect Sheet.doc Att 5_Resp Data Collect Sheet IC Document
Attach 6 - Thank you letter.doc Att 6_Thank you Letter IC Document
Attach 7 - Special Consent.docx Att 7_Special Consent IC Document

Information Collection (IC) Details

IC Title:	Collaborating Center for Questionnaire Design and Evaluation Research (CCQDER)	Agency IC Tracking Number:	0920-0222 (18AGM)

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Electronic Capability
Form and Instruction	0920-0222	National Study of Long-Term Care Provider 2016 Adult Day Services Center Questionnaire	Attach 1a - ADSC Questionnaire-v2 051418.pdf	No	Fillable Fileable
Form and Instruction	0920-0222	Adult Day Care Services Center (ADSC) Telephone Screening Script	Attach 3a - ADSC Telephone Screener.docx	No	Fillable Fileable
Form and Instruction	0920-0222	Residential Care Community (RCC) Telephone Screening Script	Attach 3b - RCC Telephone Screener.docx	No	Fillable Fileable
Form and Instruction	0920-0222	National Study of Long-Term Care Providers 2016 Residential Care Community Questionnaire	Attach 1b - RCC Questionnaire-v2 051418.pdf	No	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title: Health and Demongraphic Surveys Conducted in Probability Samples of the U.S. Population	FR Citation: 49 FR 37693

Number of Respondents: 112	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	112	112
Annual IC Time Burden (Hours)	46	46
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
LTCSB 10-day Letter	LTCSB10-day letter 051418.docx	05/17/2018
Att 2_Advance Letter	Attach 2 - Advance Letter.docx	05/17/2018
Att 4_Informed Consent	Attach 4 - Informed Consent.doc	05/17/2018
Att 5_Resp Data Collect Sheet	Attach 5 - Resp Data Collect Sheet.doc	05/17/2018
Att 6_Thank you Letter	Attach 6 - Thank you letter.doc	05/17/2018
Att 7_Special Consent	Attach 7 - Special Consent.docx	05/17/2018

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