Information Collection

Experiments to Support the Redesign of the National Survey of Children's Health

IC 212514 under ICR 201402-0915-003 · OMB 0915-0379.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0379 can be found here:

Documents and Forms

Document Name Document Type
Form 1 Experiments to Support the Redesign of the National Survey of Children's Health Form and Instruction
1 0-5 Long Instrument 0_5 FORMATTED Long v1.2.pdf Form and Instruction
2 0-5 Short Instrument 0-5 UNFORMATTED Short_v1.2 - Copy.docx Form and Instruction
3 6-11 Long Instrument 6-11 UNFORMATTED Long_v1.2.docx Form and Instruction
4 6-11 Short Instrument 6-11 UNFORMATTED Short_v1.2.docx Form and Instruction
5 12-17 Long Instrument 12-17 UNFORMATTED Long_v1.2.docx Form and Instruction
6 12-17 Short Instrument 12-17 UNFORMATTED Short_v1.2.docx Form and Instruction
7 Recruitment Screener Cognitives Recruitment Screener.docx Form and Instruction
8 Provider Form Provider Form.docx Form and Instruction
9 Provider Form Provider Form_Phone.docx Form and Instruction
10 Test-Retest TestRetestInstrument v1.2.docx Form and Instruction
Cognitive Interview Consent Script.docx Cognitive Interview Consent Script IC Document
Mail Consent Script.docx Mail Consent Script IC Document
Phone Consent Script.docx Phone Consent Script IC Document
Web Consent Script.docx Web Consent Script IC Document
Supporting Statement A.docx Supporting Statement A IC Document
Supporting Statement B.docx Supporting Statement B IC Document
Protocol_Cognitive_OMB.docx Cognitive Protocol IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Experiments to Support the Redesign of the National Survey of Children's Health	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	0-5 Long Instrument	0_5 FORMATTED Long v1.2.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	2	0-5 Short Instrument	0-5 UNFORMATTED Short_v1.2 - Copy.docx	Yes	Yes	Fillable Fileable
Form and Instruction	3	6-11 Long Instrument	6-11 UNFORMATTED Long_v1.2.docx	Yes	Yes	Fillable Fileable
Form and Instruction	4	6-11 Short Instrument	6-11 UNFORMATTED Short_v1.2.docx	Yes	Yes	Fillable Fileable
Form and Instruction	5	12-17 Long Instrument	12-17 UNFORMATTED Long_v1.2.docx	Yes	Yes	Fillable Fileable
Form and Instruction	6	12-17 Short Instrument	12-17 UNFORMATTED Short_v1.2.docx	Yes	Yes	Fillable Fileable
Form and Instruction	7	Recruitment Screener	Cognitives Recruitment Screener.docx	Yes	Yes	Fillable Fileable
Form and Instruction	8	Provider Form	Provider Form.docx	No		Paper Only
Form and Instruction	9	Provider Form	Provider Form_Phone.docx	No		Paper Only
Form and Instruction	10	Test-Retest	TestRetestInstrument v1.2.docx	No		Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 9,486	Number of Respondents for Small Entity: 15

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 33 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	9,486	9,486
Annual IC Time Burden (Hours)	1,595	1,595
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Cognitive Interview Consent Script	Cognitive Interview Consent Script.docx	07/31/2014
Mail Consent Script	Mail Consent Script.docx	07/31/2014
Phone Consent Script	Phone Consent Script.docx	07/31/2014
Web Consent Script	Web Consent Script.docx	07/31/2014
Supporting Statement A	Supporting Statement A.docx	08/21/2014
Supporting Statement B	Supporting Statement B.docx	07/31/2014
Cognitive Protocol	Protocol_Cognitive_OMB.docx	07/31/2014

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