Information Collection

Cognitive Testing of National Survey of Hospital-Based Victim Services (NSHVS)

IC 228398 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⚠️ Notice: This information collection may be referencing outdated material.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
Attach 6 Telephone Screener.docx Other-Telephone script
National Survey of Hospital-based Victim Services Attach 1 Questionnaire 090817.docx Form
Respondent Data Sheet Attach 8 Respondent Data Sheet.docx Form
Attach 2 Invitational Letter.docx Invitation letter IC Document
Attach 3 Newspaper Ad&Flyer.docx Advertisement IC Document
Attach 4 Support Letter.docx Letter of Support IC Document
Attach 5 Interviewer Intro Ltr.docx Introductory Letter IC Document
Attach 7 Informed Consent.docx Consent IC Document
Attach 9 Thank You Ltr.docx Thank you Letter IC Document
Attach 10 Special Consent.docx Consent for Recording IC Document
10-day letter Hospital based 092917.docx OMB request letter IC Document

Information Collection (IC) Details

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	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

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 Agency Discretion
Annual Number of Responses for this IC	92	92
Annual IC Time Burden (Hours)	26	26
Annual IC Cost Burden (Dollars)	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.