National Health Interview Survey

Forms and Documents

Document Name	Status
Form 3g National Health Interview Survey--Line 7 Form and Instruction	Modified
Form 3e Teen Record Check--Line 6 Form and Instruction	Modified
Form 3d Child Record Check--Line 5 Form and Instruction	Modified
Form 3c Child Core--line 4 Form and Instruction	Modified
Form 3b Adult Core--line 3 Form and Instruction	Modified
Form 3a Family Core - line 2 Form and Instruction	Modified
Form 1 Screener Questionnaire--Line 1 Form and Instruction	Modified
Form 3h Reinterview Survey--Line 9 Form and Instruction	Modified
Form 3f Supplements--Line 8 Form and Instruction	Modified
Justification for Change Updated.doc Justification for No Material/Nonsubstantive Change	2011-10-20
NHIS 83 C 2012 supporting statement new questions Rev. 101811.doc Justification for No Material/Nonsubstantive Change	2011-10-20
2012 NHIS New Questions.pdf Supplementary Document	2011-08-31
OMB2012Q1ChangeV1.doc Justification for No Material/Nonsubstantive Change	2011-08-31
Attachment4 Cover.doc Supplementary Document	2008-08-07

IC Document Collections

IC ID	Document Title	Status
45692	National Health Interview Survey--Line 7 Form and Instruction	Modified
45691	Teen Record Check--Line 6 Form and Instruction	Modified
45690	Child Record Check--Line 5 Form and Instruction	Modified
45689	Child Core--line 4 Form and Instruction	Modified
45688	Adult Core--line 3 Form and Instruction	Modified
45687	Family Core - line 2 Form and Instruction	Modified
37725	Screener Questionnaire--Line 1 Form and Instruction	Modified
186085	Reinterview Survey--Line 9 Form and Instruction	Modified
186084	Supplements--Line 8 Form and Instruction	Modified

ICR Details

OMB Control No: 0920-0214	ICR Reference No: 201109-0920-003
Status: Historical Active	Previous ICR Reference No: 201107-0920-008
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: 10/25/2011
	Date Received in OIRA: 09/12/2011
Terms of Clearance: NHIS can continue to submit re-introduction of modules used in the past (and thus have gone through the public comment process in the past) as non-substantive changes. However, please remember that any new modules must be submitted as substantive changes.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2014	08/31/2014	08/31/2014
Responses	212,940	0	212,940
Time Burden (Hours)	55,343	0	55,343
Cost Burden (Dollars)	0	0	0

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Abstract: The annual NCHS National Health Interview Survey (NHIS) is a major source of general statistics on the health of the U.S. population and has been in the field every year since 1957. This household-based survey collects demographic and health-related information on a nationally representative sample of households throughout the country. This change request is to cycle out fitness center use questions and cycle in questions on several topics for 2012.

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Authorizing Statute(s): PL: Pub.L. 111 - 148 1 Name of Law: The Patient Protection and Affordable Care Act
   PL: Pub.L. 104 - 170 136 Name of Law: The Food Quality Protection Act of 1996
   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
   US Code: 42 USC 306 Name of Law: Public Health Service Act
  

Citations for New Statutory Requirements: None

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

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Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? Yes

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

IC Title	Form No.	Form Name
Child Record Check--Line 5	3d	Child Record Check--Immunization History Questionnaire
Teen Record Check--Line 6	3e	National Health Interview Provider Survey--Teen
National Health Interview Survey--Line 7	3g	Child Immunization Provider--NHIS Instrument Spec Report
Supplements--Line 8	3f	Family Health Insurance--Health Care Reform
Reinterview Survey--Line 9	3h	2011 NHIS Reinterview Instrument Screens
Family Core - line 2	3a	Family Core
Screener Questionnaire--Line 1	1	OMB Statement and Screener Section of the
Adult Core--line 3	3b	Adult Core
Child Core--line 4	3c	2011 NHIS Questionnaire--Sample Child

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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	212,940	212,940	0	0	0	0
Annual Time Burden (Hours)	55,343	55,343	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:

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Annual Cost to Federal Government: $31,000,000

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]? Yes

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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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: 09/12/2011

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