National Health Interview Survey

Forms and Documents

Document Name	Status
Form Not Assigned NHIS 2007 Child Topical Module Form and Instruction	Modified
Form Not Assigned NHIS 2007 Child Core Questionnaire Form and Instruction	Modified
Form Not Assigned NHIS 2007 Adult Core Questionnaire Form and Instruction	Modified
Form Not Assigned NHIS 2007 Family Core Questionnaire Form and Instruction	Modified
Form None Assigned NHIS 2007 Screener Questionnaire Form and Instruction	Modified
Form Not Assigned NHIS 2007 Reinterview Survey Form and Instruction	Modified
Form CDC 64.122 NIS 2008 Teen Immunization Questionnaire Form	Modified
Form CDC 64.122 NIS 2008 Child Immunization Questionnaire Form	Modified
NHIS 83 C 2009 REVISED s.s. 121908.doc Supplementary Document	2008-12-24
NHIS 83 C 2009 REVISED s.s. 121908.doc Supplementary Document	2008-12-24
NHIS 2009 Attach 2 Reintv Questions (2).doc Supplementary Document	2008-11-20
NHIS 2009 Attach 1 New 09 Questions (2).doc Supplementary Document	2008-11-20
NHIS 83 C 2009 Supporting Statement 111708 (final).doc Justification for No Material/Nonsubstantive Change	2008-11-20
Attachment4 Cover.doc Supplementary Document	2008-08-07
Attachment3 Cover.doc Supplementary Document	2008-08-07

IC Document Collections

IC ID	Document Title	Status
45692	NHIS 2007 Child Topical Module Form and Instruction	Modified
45691	NHIS 2007 Child Core Questionnaire Form and Instruction	Modified
45690	NHIS 2007 Adult Topical Module Instruction	Modified
45689	NHIS 2007 Adult Core Questionnaire Form and Instruction	Modified
45688	NHIS 2007 Family Core Questionnaire Form and Instruction	Modified
45687	NHIS 2007 Screener Questionnaire Form and Instruction	Modified
37725	NHIS 2007 Reinterview Survey Form and Instruction	Modified
186085	NIS 2008 Teen Immunization Questionnaire Form	Modified
186084	NIS 2008 Child Immunization Questionnaire Form	Modified

ICR Details

OMB Control No: 0920-0214	ICR Reference No: 200811-0920-004
Status: Historical Active	Previous ICR Reference No: 200808-0920-005
Agency/Subagency: HHS/CDC	Agency Tracking No:
Title: National Health Interview Survey
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 12/29/2008
	Date Received in OIRA: 11/28/2008
Terms of Clearance: Prior terms continue. Health IT questions are approved for one administration only as further development is needed to determine the most useful questions to be asking.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2009	12/31/2009	12/31/2009
Responses	119,600	0	119,600
Time Burden (Hours)	28,017	0	28,017
Cost Burden (Dollars)	0	0	0

---

Abstract: The National Health Interview Survey collections demographic and health-related infromation. This change seeks approval to cycle out questions on asthma, oral health, vision, heart disease, cancer screening, immunization, and dizziness, balance problems and falls fielded in 2008, and to cycle in and update questions on carbon monoxide detectors, stroke, arthritis, health care workers, and the use of the internet to learn about health information or to communicate with health care providers for 2009. We also seek approval for revised questions in the reinterview questionnaire used to monitor survey protocols.

---

Authorizing Statute(s): US Code: 42 USC 242 Name of Law: Public Health Service Act
   PL: Pub.L. 101 - 445 301 Name of Law: The National Nutrition Monitoring and Related Research Act of 1990
   PL: Pub.L. 104 - 170 136 Name of Law: The Food Quality Protection Act of 1996
  

Citations for New Statutory Requirements: None

---

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

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	71 FR 36096	06/23/2006
30-day Notice:	Federal Register Citation:	Citation Date:
	71 FR 55476	09/22/2006
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 9

IC Title	Form No.	Form Name
NHIS 2007 Reinterview Survey	Not Assigned	Reinterview Survey
NHIS 2007 Adult Core Questionnaire	Not Assigned, Not Assigned, Not Assigned, Not Assigned, Not Assigned, Not Assigned, Not Assigned	Adult Identification ,   Adult Health Behaviors ,   Adult Health Status and Limitations ,   Adult Socio-Demographic ,   Adult Conditions ,   Adult Access to Health Care and Utilization ,   Adult AIDS Knowledge and Attitudes
NHIS 2007 Screener Questionnaire	None Assigned, None Assigned	Screener Survey ,   Screener Questionnaire
NHIS 2007 Family Core Questionnaire	Not Assigned, Not Assigned, Not Assigned, Not Assigned, Not Assigned, Not Assigned, Not Assigned, Not Assigned	Family Identification ,   Family Health Status and Limitations ,   Family Injury and Poisoning ,   Family Access to Health Care and Utilization ,   Family Health Insurance ,   Family Socio-Demographic ,   Family Income ,   Recontact
NHIS 2007 Adult Topical Module
NHIS 2007 Child Core Questionnaire	Not Assigned, Not Assigned, Not Assigned, Not Assigned, Not Assigned, Not Assigned	Child Health Status and Limitations ,   Child Access to Health Care and Utilization ,   Child Identification ,   Child Mental Health Brief Questionnaire ,   Child Mental Health Services ,   Child Influenza Immunization
NHIS 2007 Child Topical Module	Not Assigned	Child Topical Module
NIS 2008 Child Immunization Questionnaire	CDC 64.122	National Immunization Survey
NIS 2008 Teen Immunization Questionnaire	CDC 64.122	National Immunization Survey - Teen

---

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	119,600	119,600	0	0	0	0
Annual Time Burden (Hours)	28,017	28,017	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

---

Annual Cost to Federal Government: $28,000,000

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]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

Is this ICR related to the Pandemic Response? Uncollected

---

Common Form ICR:  No

---

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: 11/28/2008

---