Collaborating Center for Questionnaire Design and Evaluation Research

Forms and Documents

Document Name	Status
Cognitive Testing of Questions on Complementary Health Approaches and Well-being Form and Instruction	New
NIOSH Virtual Cognitive Interview Study Form and Instruction	New
Form 0920-0222 Cognitive Testing of 2021 Occupational Health Supplement Questions Form	New
National Health and Nutrition Examination Survey (NHANES – Growth Chart) Form and Instruction	New
Form 0920-0222 NSFG Life History Calendar Evaluation Form and Instruction	New
Cognitive Testing for American Community Survey Form and Instruction	New
Cognitive Interview Study: Spanish-language Telephone-administered Questions for PRAMS (2019) Form and Instruction	New
Cognitive Testing of Physician Opioid Questions Form	New
Form 0920-0222 Cognitive Test for the Pregnancy Risk Assessment Monitoring System (PRAMS) Form and Instruction	New
Form 0920-0222 Cognitive Test for NHIS Questions and Opiods Form and Instruction	New
Cognitive Test for ACS Disability Questions and NHIS Child Behavior Questions Form and Instruction	New
Form 0920-0222 NCHS Research and Development Survey (RANDS) Form and Instruction	New
PRAMS Opioid 2018 -Spanish Form	New
PRAMS Opioid 2018 - English Form	New
qvideo_PIA_signed.pdf Supplementary Document	2018-07-24
Privacy Act App Review CCQDER 062918.docx Supplementary Document	2018-07-12
Att N Explain cog interview 062718.doc Supplementary Document	2018-07-12
Att M Sample Resp data collect sheet 070218.doc Supplementary Document	2018-07-12
Att L Sample advance letter.doc Supplementary Document	2018-07-12
Att K Voice mail script.doc Supplementary Document	2018-07-12
Att J Sample newspaper adv.doc Supplementary Document	2018-07-12
Att I Sample flyer.doc Supplementary Document	2018-07-12
Att H NCHS ERB approval.rtf Supplementary Document	2018-07-12
Att G Spec consent focus group 062718.docx Supplementary Document	2018-07-12
Att F Spec consent Cog Int 062718.docx Supplementary Document	2018-07-12
Att E informed consent 062718.doc Supplementary Document	2018-07-12
Att D screening script 062718.doc Supplementary Document	2018-07-12
Att C Nondisclosure Affidavits 062718.doc Supplementary Document	2018-07-12
Att B 60-Day Notice 062718.pdf Supplementary Document	2018-07-12
Supp Statement A clean 070218 ICRO edited.docx Supporting Statement A	2018-07-12
Att A Pub Health Serv Act.doc Supplementary Document	2015-06-11
Supp Statement B 070218.docx Supporting Statement B	2018-07-12

IC Document Collections

IC ID	Document Title	Status
244069	NSCH "Healthy and Ready to Learn" Questions 2020 (Self-administered/English) Other-WORD	New
243885	Cognitive Testing of Questions on Complementary Health Approaches and Well-being Form and Instruction	New
243825	NIOSH Virtual Cognitive Interview Study Form and Instruction	New
240112	Cognitive Testing of 2021 Occupational Health Supplement Questions Form	New
239465	The Research and Development Survey (RANDS 4 -- Telephone Sample) Other-WORD	New
239376	National Health and Nutrition Examination Survey (NHANES – Growth Chart) Form and Instruction	New
238942	NSFG Life History Calendar Evaluation Form and Instruction	New
237460	Cognitive Testing for American Community Survey Form and Instruction	New
236479	Cognitive Interview Study: Spanish-language Telephone-administered Questions for PRAMS (2019) Form and Instruction	New
236379	Cognitive Testing of Physician Opioid Questions Form	New
236175	Cognitive Test for the Pregnancy Risk Assessment Monitoring System (PRAMS) Form and Instruction	New
236133	Cognitive Test for NHIS Questions and Opiods Form and Instruction	New
236115	Cognitive Test for ACS Disability Questions and NHIS Child Behavior Questions Form and Instruction	New
236041	Validity Study of Intellectual and Disability Questions Other-WORD	New
233931	NCHS Research and Development Survey (RANDS) Form and Instruction	New
233753	PRAMS Opioid 2018 -Spanish Form	New
233751	PRAMS Opioid 2018 - English Form	New

ICR Details

OMB Control No: 0920-0222	ICR Reference No: 201807-0920-004
Status: Active	Previous ICR Reference No: 201506-0920-003
Agency/Subagency: HHS/CDC	Agency Tracking No: 0920-0222
Title: Collaborating Center for Questionnaire Design and Evaluation Research
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 08/31/2018
	Date Received in OIRA: 07/27/2018
Terms of Clearance: CDC will continue to submit individual collections under this generic clearance to OMB. OMB will strive to provide feedback on the individual collections within ten working days, whenever possible, as is currently the case. Standard remuneration of respondents for cognitive testing ($40) and focus groups ($75) applies until research is presented suggesting these rates should be changed or in situation where evidence already exists that a particular subpopulation requires a higher incentive.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2021	36 Months From Approved	08/31/2018
Responses	56,100	0	24,000
Time Burden (Hours)	23,350	0	13,150
Cost Burden (Dollars)	0	0	0

---

Abstract: This generic clearance request encompasses general questionnaire development, pre-testing, measurement-error reduction activities to be carried out in 2018-2021 in the Division of Research and Methodology, National Center for Health Statistics (NCHS), Centers for Disease Control and Prevention (CDC). The revision requested consists of an increase in burden hours for the next 3-year approval period. The difference is due to an anticipated increase in the number and size of projects being undertaken.

---

Authorizing Statute(s): US Code: 42 USC 242k Name of Law: Public Health Service Act
  

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:
	83 FR 8875	03/01/2018
30-day Notice:	Federal Register Citation:	Citation Date:
	83 FR 35646	07/27/2018
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 17

IC Title	Form No.	Form Name
PRAMS Opioid 2018 -Spanish	none, none, none	PRAMS Opioid 2018 - Spanish ,   Telephone Screener - Spanish ,   Respondent Data Collection Sheet
PRAMS Opioid 2018 - English	none, none, none	PRAMS Opioid 2018 ,   Telephone Screener ,   Respondent Data Sheet
Cognitive Testing of Physician Opioid Questions	none, none	National Survey on Best Practices for Patient Pain Management and Opioid Use ,   Respondent data collection sheet
Cognitive Test for ACS Disability Questions and NHIS Child Behavior Questions	n/a, n/a, n/a	Telephone Screener ,   ACS Booklet and Selected NHIS Questions Discussed During the Cognitive Interview ,   Respondent Data Collection Sheet (Demographics)
NIOSH Virtual Cognitive Interview Study	none, none, none	Telephone screener ,   NIOSH questionnaire ,   Respondent data sheet
NSCH "Healthy and Ready to Learn" Questions 2020 (Self-administered/English)
Cognitive Testing of 2021 Occupational Health Supplement Questions	0920-0222, 0920-0222	Questions for Consideration NHIS-OHS 2021 Supplement ,   Respondent Data Collection Sheet
NCHS Research and Development Survey (RANDS)	0920-0222	Web Questionnaire Introduction Screen and RANDS Questionnaire
NSFG Life History Calendar Evaluation	0920-0222, 0920-0222, 0920-0222, 0920-0222, 0920-0222	Attachment 1a: Questions to be cognitively tested ,   Attachment 1b - Life History Calendar Worksheet (Recall Aide) ,   Attachment 3a – Telephone Screening Script – Respondent recruited from newspaper advertisement/flyer ,   Attachment 3b – Telephone Screening Script – Respondent recruited from CCQDER Respondent Database ,   Attachment 5: Respondent Data Collection Sheet
Cognitive Testing for American Community Survey	none, none, none	Telephone screeners ,   Interview instrument ,   Respondent data collection sheets
Cognitive Testing of Questions on Complementary Health Approaches and Well-being	n/a, n/a, n/a	Telephone Screener ,   NHIS Complementary Health Approaches and Well-being Questionnaire ,   Respondent Data Collection Sheet [demographics]
National Health and Nutrition Examination Survey (NHANES – Growth Chart)	n/a, n/a	Focus Group Protocol (NHANES Growth Chart) ,   Data Collection Sheet (participant demographics)
Validity Study of Intellectual and Disability Questions
Cognitive Interview Study: Spanish-language Telephone-administered Questions for PRAMS (2019)	n/a, n/a, n/a	Telephone Screening Script (in Spansih) ,   PRAMS 2019 questions to be cognitively tested (Phone/Spanish version) ,   Respondent Data Sheet (in Spanish)
Cognitive Test for NHIS Questions and Opiods	0920-0222, 0920-0222, 0920-0222	Questions to be Cognitively Tested ,   Screeners ,   Respondent Data Collection Sheet
Cognitive Test for the Pregnancy Risk Assessment Monitoring System (PRAMS)	0920-0222, 0920-0222, 0920-0222	2019 Questions for Cognitive Testing ,   Screener ,   Respondent Data
The Research and Development Survey (RANDS 4 -- Telephone Sample)

---

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	56,100	24,000	0	32,100	0	0
Annual Time Burden (Hours)	23,350	13,150	0	10,200	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

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

Burden Reduction Due to:

Short Statement: The increase in burden is due to an anticipated increase in the number and size of projects being undertaken.

---

Annual Cost to Federal Government: $2,229,740

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

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

---

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: 07/27/2018

---