Cognitive Interview Screener

Child Health Disparities Substudy for the National Children's Study (NCS)- Phase 1

Documents and Forms

Document Name Document Type
Form 1.1 Cognitive Interview Screener Form and Instruction
1.1 Survey Attach 2. In-person Screening Script.docx Form and Instruction
1.2 Survey Attach 3. Telephone Screening Script.doc Form and Instruction
1.3 Survey Attach 5. Cognitive Interview Screener.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Cognitive Interview Screener	Agency IC Tracking Number:

Is this a Common Form? No		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	1.1	Survey	Attach 2. In-person Screening Script.docx	Yes	Yes	Paper Only
Form and Instruction	1.2	Survey	Attach 3. Telephone Screening Script.doc	Yes	Yes	Paper Only
Form and Instruction	1.3	Survey	Attach 5. Cognitive Interview Screener.docx	Yes	Yes	Paper Only

Line of Business: General Science and Innovation

Subfunction: Scientific and Technological Research and Innovation

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 100	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	100	100
Annual IC Time Burden (Hours)	8	8
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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