Information Collection

Cognitive Interviewing Study of Opioid-Related Questions (Spanish Version)

IC 231500 under ICR 201506-0920-003 · OMB 0920-0222.

⚠️ Notice: This information collection may be referencing outdated material.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
Cognitive Interviewing Study of Opioid-Related Questions (Spanish Version) Form and Instruction
Sample screening script for respondent contact Cognitive Attach 3 Spanish Telephone Screener 051518.docx Form and Instruction
Spanish Questions to be cognitively tested Attach 1 Spanish Questionnaire.doc Form and Instruction
Spanish Respondent Data Collection Sheet Attach 5 Spanish Resp Data Collect.docx Form and Instruction
Spanish Opioid 10-day 051518.docx Project Description (10-day Letter) IC Document
Attach 2 Spanish Advertisement.docx Recruitment Ad for Spanish Speaking Participants IC Document
Attach 4 Spanish Informed Consent.docx Informed Consent Form for Spansih Study IC Document
Attach 6 Spanish Thank You Letter.docx Thank You Letter IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Cognitive Interviewing Study of Opioid-Related Questions (Spanish Version)	Agency IC Tracking Number:	0920-18AHJ

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	n/a	Sample screening script for respondent contact Cognitive interviewing study of opioid use and pain questions	Attach 3 Spanish Telephone Screener 051518.docx	No	Paper Only
Form and Instruction	n/a	Spanish Questions to be cognitively tested	Attach 1 Spanish Questionnaire.doc	No	Paper Only
Form and Instruction	n/a	Spanish Respondent Data Collection Sheet	Attach 5 Spanish Resp Data Collect.docx	No	Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title: Health and Demographic Surveys Conducted in Probability Samples of the U. S. Population 09-20-0164	FR Citation: 49 FR 37693

Number of Respondents: 96	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	96	96
Annual IC Time Burden (Hours)	68	68
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Project Description (10-day Letter)	Spanish Opioid 10-day 051518.docx	05/17/2018
Recruitment Ad for Spanish Speaking Participants	Attach 2 Spanish Advertisement.docx	05/17/2018
Informed Consent Form for Spansih Study	Attach 4 Spanish Informed Consent.docx	05/17/2018
Thank You Letter	Attach 6 Spanish Thank You Letter.docx	05/17/2018

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