Information Collection

Assessment of Characteristics of State Crash Outcome Data Evaluation Systems

IC 204845 under ICR 201110-0920-004 · OMB 0920-0879.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0879 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-0879 Assessment of Characteristics of State Crash Outcome Data Evaluation Systems	Form and Instruction
Attachment O survey reminder email 10312012l.docx	Instruction
0920-0879 Attachment K Screen shot of questionnaire Attachment K Screen shot of questionnaire.pdf	Form and Instruction
0920-0879 AttachmentJ - Questionnaire WORD version AttachmentJ - Questionnaire WORD version 10312012.docx	Form and Instruction
0920-0879 Attachment M Email notification 10312012 Attachment M Email notification 10312012.docx	Form and Instruction
0920-0879 Attachment N Email with survey link Attachment N Email with survey link 10312012.docx	Form and Instruction
Supporting statement A - 11-9-2012.docx Supporting Statement A	IC Document
Supporting Statement B - 11-9-2012.docx Supporting Statement B	IC Document
Attachmen C - sample ED record.doc Attachmen C - sample ED record	IC Document
Attachment A NHTSA 2010 Traffic Safety Facts.pdf Attachment A NHTSA 2010 Traffic Safety Facts	IC Document
Attachment B Police crash report.pdf Attachment B Police crash report	IC Document
Attachment D - sample inpatient record.TXT Attachment D - sample inpatient record	IC Document
Attachment E - Motor_Vehicle_WB_Letter.pdf Attachment E - Motor_Vehicle_WB_Letter	IC Document
Attachment F RFP for CODES.pdf Attachment F RFP for CODES	IC Document
Attachment G - Oriiginal multi state report.pdf Attachment G - Oriiginal multi state report	IC Document
Attachment H catalog of CODES projects.pdf Attachment H catalog of CODES projects	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Assessment of Characteristics of State Crash Outcome Data Evaluation Systems

Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	0920-0879	Attachment K Screen shot of questionnaire	Attachment K Screen shot of questionnaire.pdf	Yes	Yes	Fillable Printable
Form and Instruction	0920-0879	AttachmentJ - Questionnaire WORD version	AttachmentJ - Questionnaire WORD version 10312012.docx	Yes	Yes	Fillable Fileable
Instruction			Attachment O survey reminder email 10312012l.docx	Yes	Yes	Printable Only
Form and Instruction	0920-0879	Attachment M Email notification 10312012	Attachment M Email notification 10312012.docx	No	No	Printable Only
Form and Instruction	0920-0879	Attachment N Email with survey link	Attachment N Email with survey link 10312012.docx	Yes	Yes	Fillable Printable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 35

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	35	35
Annual IC Time Burden (Hours)	18	18
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Supporting Statement A	Supporting statement A - 11-9-2012.docx	11/13/2012
Supporting Statement B	Supporting Statement B - 11-9-2012.docx	11/13/2012
Attachmen C - sample ED record	Attachmen C - sample ED record.doc	11/13/2012
Attachment A NHTSA 2010 Traffic Safety Facts	Attachment A NHTSA 2010 Traffic Safety Facts.pdf	11/13/2012
Attachment B Police crash report	Attachment B Police crash report.pdf	11/13/2012
Attachment D - sample inpatient record	Attachment D - sample inpatient record.TXT	11/13/2012
Attachment E - Motor_Vehicle_WB_Letter	Attachment E - Motor_Vehicle_WB_Letter.pdf	11/13/2012
Attachment F RFP for CODES	Attachment F RFP for CODES.pdf	11/13/2012
Attachment G - Oriiginal multi state report	Attachment G - Oriiginal multi state report.pdf	11/13/2012
Attachment H catalog of CODES projects	Attachment H catalog of CODES projects.pdf	11/13/2012

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