Information Collection

Evaluation of Traumatic Brain Injury Questions for CDC's National Center for Injury Prevention and Control (NCIPC)

IC 221813 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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
Document Name	Document Type
Telephone Screening Script for Adult/Self-Responder or Adult Proxy for Child 5-17 Evaluation of Traumatic Brain Injury Questions for CDC's National Center for Injury Prevention and Control (NCIPC)	Form and Instruction
Questions to be Cognitively Tested Evaluation of Traumatic Brain Injury Questions for CDC's National Center for Injury Prevention and Control (NCIPC)	Form and Instruction
Telephone Screening Script for Adult/Self-Responder or A TBI Attach 3ab Screener 060316.docx	Form and Instruction
Questions to be Cognitively Tested TBI Attach 1 Questionnaire 060216.docx	Form and Instruction
TBI 10-day letter 060216.docx GenIC Request - Cognitive Testing	IC Document
TBI Attach 2a-e AdFlyers 060216.docx Advertisement / Flyer	IC Document
TBI Attach 4a-c Informed Consent&Assent.docx Informed Consent and Assent	IC Document
TBI Attach 5 Resp Data Collection Sheet.docx Adult Respondent Data Collection Sheet	IC Document
TBI Attach 6 Thank You letter.docx Thank You Letter	IC Document
TBI Attach 7 Adult Special Consent.docx Special Consent for Expanded Use of Video and Audio Recordings	IC Document

IC Title:

Evaluation of Traumatic Brain Injury Questions for CDC's National Center for Injury Prevention and Control (NCIPC)

Agency IC Tracking Number:

16APT

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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	NA	Questions to be Cognitively Tested	TBI Attach 1 Questionnaire 060216.docx	NA	No		Paper Only
Form and Instruction	NA	Telephone Screening Script for Adult/Self-Responder or Adult Proxy for Child 5-17	TBI Attach 3ab Screener 060316.docx	NA	No		Fillable Printable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: 09-20-0164 Health and Demographic Surveys Conducted in Probability Samples of the U.S. Population

FR Citation: 49 FR 37693

Number of Respondents: 112

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	112	112
Annual IC Time Burden (Hours)	46	46
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
GenIC Request - Cognitive Testing	TBI 10-day letter 060216.docx	06/07/2016
Advertisement / Flyer	TBI Attach 2a-e AdFlyers 060216.docx	06/07/2016
Informed Consent and Assent	TBI Attach 4a-c Informed Consent&Assent.docx	06/07/2016
Adult Respondent Data Collection Sheet	TBI Attach 5 Resp Data Collection Sheet.docx	06/07/2016
Thank You Letter	TBI Attach 6 Thank You letter.docx	06/07/2016
Special Consent for Expanded Use of Video and Audio Recordings	TBI Attach 7 Adult Special Consent.docx	06/07/2016

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