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Agenda
Reg Review
ICR
View Information Collection (IC)
View Information Collection (IC)
IC Title:
Cognitive Testing of National Survey of Hospital-Based Victim Services (NSHVS)
Agency IC Tracking Number:
0920-0222-17BCS
IC Status:
New
Obligation to Respond:
Voluntary
CFR Citation:
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Other-Telephone script
Attach 6 Telephone Screener.docx
Yes
Yes
Fillable Fileable
Form
none
National Survey of Hospital-based Victim Services
Attach 1 Questionnaire 090817.docx
Yes
Yes
Fillable Fileable
Form
none
Respondent Data Sheet
Attach 8 Respondent Data Sheet.docx
Yes
Yes
Fillable Fileable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Public Health Monitoring
Privacy Act System of Records
Title:
Health and Demographic Surveys Conducted in Probablity Samples of the US Population
FR Citation:
49 FR 37693
Number of Respondents:
92
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
0 %
Approved
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
92
0
92
0
0
0
Annual IC Time Burden (Hours)
26
0
26
0
0
0
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
Invitation letter
Attach 2 Invitational Letter.docx
09/20/2017
Advertisement
Attach 3 Newspaper Ad&Flyer.docx
09/20/2017
Letter of Support
Attach 4 Support Letter.docx
09/20/2017
Introductory Letter
Attach 5 Interviewer Intro Ltr.docx
09/20/2017
Consent
Attach 7 Informed Consent.docx
09/20/2017
Thank you Letter
Attach 9 Thank You Ltr.docx
09/20/2017
Consent for Recording
Attach 10 Special Consent.docx
09/20/2017
OMB request letter
10-day letter Hospital based 092917.docx
09/29/2017
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.