Information Collection

Spanish Cognitive Study to Examine Traumatic Brain Injury Questions

IC 223018 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⚠️ Notice: This information collection may be referencing outdated material.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
Spanish Cognitive Study to Examine Traumatic Brain Injury Questions	Form
Spanish Questions - TBI Spanish TBI Attach 1 Qnne.docx	Form
Spanish Telephone Screener Spanish TBI Attach 3 phone screener.docx	Form and Instruction
Spanish Data Collection Sheet Spanish TBI Attach 5 Resp Data Collect.docx	Form
Spanish TBI 10-day letter 081116.docx Letter to Dr. Schwab	IC Document
Spanish TBI Attach 2a&b ad&flyer.docx Advertisement/Flyer	IC Document
Spanish TBI Attach 4 Informed Consent.docx Consent	IC Document
Spanish TBI Attach 6 ThankYou letter.docx Thank you Letter	IC Document
Spanish TBI Attach 7 Special Consent.docx Video Consent	IC Document

IC Title:

Spanish Cognitive Study to Examine Traumatic Brain Injury Questions

Agency IC Tracking Number:

16AZR

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	none	Spanish Questions - TBI	Spanish TBI Attach 1 Qnne.docx	Yes	No	Fillable Fileable
Form and Instruction	none	Spanish Telephone Screener	Spanish TBI Attach 3 phone screener.docx	Yes	No	Fillable Fileable
Form	none	Spanish Data Collection Sheet	Spanish TBI Attach 5 Resp Data Collect.docx	Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 58

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	58	58
Annual IC Time Burden (Hours)	14	14
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Letter to Dr. Schwab	Spanish TBI 10-day letter 081116.docx	08/15/2016
Advertisement/Flyer	Spanish TBI Attach 2a&b ad&flyer.docx	08/15/2016
Consent	Spanish TBI Attach 4 Informed Consent.docx	08/15/2016
Thank you Letter	Spanish TBI Attach 6 ThankYou letter.docx	08/15/2016
Video Consent	Spanish TBI Attach 7 Special Consent.docx	08/15/2016

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