Assessment of Characteristics of State Crash Outcome Data Evaluation Systems

Surveys of State, Tribal, Local and Territorial (STLT) Governmental Health Agencies

OMB: 0920-0879

IC ID: 204845

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

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:

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 %

	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

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.