HINTS 5 Cognitive Testing

Questionnaire Cognitive Interviewing and Pretesting (NCI)

Documents and Forms

Document Name Document Type
Form 1 HINTS 5 Cognitive Testing Form and Instruction
1 Attachment C Screening Questionnaire Attach C - Screening Questionnaire.docx Form and Instruction
2 Attachment D Consent Form Attach D - Consent form.docx Form and Instruction
3 Attachment E Questionnaire Content Attachment E - Questionnaire Content.docx Form and Instruction
4 Attachment F Interview Protocol Attachment F - Interview Protocol.docx Form and Instruction
Attachment A - Westat IRB Approval.pdf Attachment A Westat IRB Approval IC Document
Attachment B - OHSRP Request for Determination Form.doc Attachment B OHSRP Request for Determination IC Document
Attachment G - Recruitment Advertisement.docx Attachment G Recruitment Advertisement IC Document
Attachment H - Reminder Letter.docx Attachment H Reminder Letter IC Document
HINTS 5 Cog Testing Mini SSA 4-6Final.docx HINTS 5 Cognitive Testing Mini SSA IC Document
HINTS 5 Cog Testing Mini SSB.docx HINTS 5 Cognitive Testing Mini SSB IC Document

Information Collection (IC) Details

IC Title:	HINTS 5 Cognitive Testing	Agency IC Tracking Number:

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 and Instruction	1	Attachment C Screening Questionnaire	Attach C - Screening Questionnaire.docx	No		Paper Only
Form and Instruction	2	Attachment D Consent Form	Attach D - Consent form.docx	No		Paper Only
Form and Instruction	3	Attachment E Questionnaire Content	Attachment E - Questionnaire Content.docx	Yes	No	Fillable Fileable
Form and Instruction	4	Attachment F Interview Protocol	Attachment F - Interview Protocol.docx	No		Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 60	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	60	60
Annual IC Time Burden (Hours)	58	58
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Attachment A Westat IRB Approval	Attachment A - Westat IRB Approval.pdf	04/11/2016
Attachment B OHSRP Request for Determination	Attachment B - OHSRP Request for Determination Form.doc	04/11/2016
Attachment G Recruitment Advertisement	Attachment G - Recruitment Advertisement.docx	04/11/2016
Attachment H Reminder Letter	Attachment H - Reminder Letter.docx	04/11/2016
HINTS 5 Cognitive Testing Mini SSA	HINTS 5 Cog Testing Mini SSA 4-6Final.docx	04/11/2016
HINTS 5 Cognitive Testing Mini SSB	HINTS 5 Cog Testing Mini SSB.docx	04/11/2016

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